Time Stamps

[Click on time stamp below to start that time mark in the audio]

  • 02:43 What is prognosis?
  • 03:58 Why offer prognostication?
  • 08:28 Why is prognostication hard?
  • 16:17  How do we improve at communicating prognosis?
  • 21:37 How should we approach uncertainty?
  • 30:26 Take Aways

Outline

  • Introduction
  • What is prognosis?
  • Why offer prognostication?
    • Clinician perspective
      • Changes medical decision making
      • Ex. Cancer screening, Diabetic control
    • Patient perspective
      • Desire to know
      • Changes treatment preferences
      • Helps organize social goals
    • Consequences to patient, clinician, and health system 
  • Why is prognostication hard?
    • Learned skill
    • Incomplete information
    • Shortcomings of prognostic calculators
    • Emotional intesity
    • Fear of getting it wrong (“chagrin factor”)
  • How do we improve it?
    • Use prognostic calculators
    • Beware of overestimation bias
    • Balance multiple estimates   
  • How do we approach uncertainty?
    • Discuss among colleagues
    • Acknowledge it upfront
    • Use a range of time 
    • “Best case/worst case/most likely case”
  • Communication tips
    • Understand patient perceptions and goals first
    • Establish patient communication preferences 
    • Avoid medical jargon and euphemisms
    • “Hope-Worry” statements
  • Conclusion

Prognostic Calculators

BODE Index for COPD (52mo mortality)

Brain Metastases Prognostic Index

Chronic Kidney Disease (Stage IV or V)

Colon Cancer

Diffuse Large B-Cell Lymphoma

ePrognosis

Palliative Performance Index (Advanced Cancer, 3mo mortality)

Multiple Myeloma (5yr mortality)

Myelodysplastic Syndrome

Pancreatic Cancer

Renal Cell Carcinoma (2 and 5yr mortality)

Rectal Cancer

Seattle Heart Failure Model (1 and 5yr mortality)

Walter’s Prognostic Index (Inpatient Geriatrics, 1yr mortality)

Transcript

Margot: “But doc – how long do I have to live?” 

Jafar: “How much time does my mom have?” 

Tamar: “Should I think about moving in with my son?”

Margot: I find that questions about prognosis are some of the hardest to answer. So many things race through my head as I stand there trying to figure out what to say. How am I supposed to know how much longer they have? How sure am I about my estimate, and what am I supposed to do with all my uncertainty? How can I tell the patient what I think, without taking away their hope? Today we’re going to try to answer those questions. I’m Margot, an internal medicine resident at NYU.

Tamar: I’m Tamar. I trained in internal medicine at NYU and am now pursuing research in bioethics. 

Jafar: and I’m Jafar, a hematology/oncology fellow at UCLA.   Today we were very lucky to sit down with Dr. Alex Smith, a national leader on prognostication. Dr. Smith trained at Brigham and Women’s in Primary Care, followed by fellowship training in Palliative Care and General Internal Medicine, and an MPH from Harvard.  He is currently faculty in the Division of Geriatrics at UCSF, and co-hosts a fantastic weekly podcast with his colleagues called GeriPal.  But his interest in prognostication began way before this long list of accomplishments:

Smith: So my interest in prognostication started, well, it started with my dad who died while I was in medical school and I had a disturbing experience. Um, he had a glioblastoma multiforme, uh, which is a brain tumor and he had stage four. It was incurable and the first treatment for it is surgical debulking of the tumor. And I went with my dad to the follow up meeting with the surgeon after the debulking and the surgeon said to my dad, I got it all, Blake–I got it all. And you know, I was in med school at the time. My dad worked at a medical school. He’s a researcher. We knew from all of the data that you cannot get all of the glioblastoma multiforme when it’s advanced, you know, the little cells have intercalated into the other neurons in the brain. And that was really, you know, uh, it was, uh, it was shocking to me at the time and, um, disturbing. 

What is prognosis?

Tamar: Dr. Smith’s personal story really moved us. It underscores exactly what we hope to explore here: the lifelong effect a conversation like this can have on a patient and his family. To start, we’ll turn it back over to Dr. Smith to define prognosis. He emphasized that this topic and its applications are somewhat broader than how we usually think of them.  

Smith: So prognosis is the likely outcome of a test or treatment or procedure. And when we talk about prognosis, we’re usually talking about prognosis for life expectancy, but prognosis can be so many more things than that.  It’s a prognosis for expected positive outcomes as well as risks and harms. So, for example, prognosis for recovery of function following an ICU admission, prognosis for developing a negative reaction to a new immunotherapy drug for example.  So prognosis is really sort of wide raging.

Margot: To give a quick disclaimer, the things that we find hardest are these conversations about lifespan, so that’s what we’ll be focusing on today. We also wanted to say that most of the literature on prognosis comes from studying geriatric patients, patients in the ICU, or those with advanced cancer.  But the broader concepts we’ll be focusing on are relevant for anyone who cares for patients with serious or life-limiting illness.

Why offer prognostication?

Jafar:  So before we get into any more details, it’s worth just coming out asking:  why do need to give any prognosis to our patients? I mean, we can’t see into the future with any certainty anyways, right?  

Tamar: Right. But maybe also not right? We certainly can’t see into the future, but we can give an informed guess. And our informed guess can help our patients make an informed decision. The risks and benefits of so many interventions change with the patient’s prognosis, and not just in decisions about end-of-life care.

Smith: So for example, in general medicine, cancer screening is the area where prognosis is probably discussed the most. And when you have a cancer screening, again, just to remind listeners is designed to detect slow growing cancers. It takes about 10 years for you to benefit from being screened for a slow growing cancer.  And if your life expectancy is less than 10 years, then you’re unlikely to benefit from the cancer screening, uh, in your lifetime. The other sort of side of the coin is about the harms of cancer screening. And those typically occur up front within the first few, either immediately, for example, with colonoscopy, the risk of colonic perforation, the burden of taking that go-lytely, which does not make you go lightly, it makes you heavily. And, um, you know, burden of false positives, you know, detection of cancers that wouldn’t hurt you in your lifetime.

Tamar: Along with cancer screening, there are many other examples where this same concept applies. Patients’ age and overall health status are important when we think about how tightly to control diabetes, or choosing between a bioprosthetic or mechanical cardiac valve, to name just a few. 

Jafar:  So it’s critical to think about prognosis on our end when it comes to the calculus of medical risks and benefits, but it’s also important to note that – at a certain point in their health – most patients want to discuss prognosis with their doctor.  Not everyone is ready to talk about it, but patients generally grow more interested in talking about prognosis the more limited it gets. A national survey of nearly 900 older adults conducted in 2016 showed that most would like to talk about it if they had less than two years of expected life.  

Tamar: Unfortunately, even when life expectancy is short, studies show that clinicians are not very good at having these discussions with patients.  In one large study of patients with advanced cancer and a median survival of less than 6 months, 70% wanted to be told their life expectancy, but only about 18% could recall ever being given a prognostic disclosure by their physician. 

Margot: If these conversations don’t happen, patients and their families will end up trying to guess for themselves. But that has its own problems: people often have very different ideas about how long a patient has to live. A study of patients with advanced cancer found that two thirds of patients surveyed had prognosis estimates that were different from their oncologist. Almost all of these discordant estimates were more optimistic, and only 11% knew that their estimates were different than their oncologist’s. This really made us wonder – are these conversations not happening? Or if they are, why isn’t it sinking in?

Tamar: And these are crucial questions because hearing about their prognosis really makes a difference in patients’ treatment preferences. One study found that patients who thought they had even just a 10% chance of dying within 6 months made significantly different choices than people who were more optimistic. 

Jafar: And prognosis doesn’t just change the way people think about their medical care–it can shape their whole world.  

Smith: Patients often want to know, not because it’s going to help them make these medical decisions, but because they want to plan for the social decisions they have to make in their lives, you know, like, should I move in with the grandkids if time is short?  You know, are there financial affairs that I need to put in order? Do I need to make sure my will is in order? Should I, you know, think about taking that trip I’ve always wanted to take? So patients want to know because they want to make primarily social decisions.

Margot: So the flip side of the scenario that Dr. Smith is describing is that patients without an idea of prognosis can suffer the consequences. It can hurt patients and their families, who end up struggling with anxiety, undesired hospitalizations, and who may opt for aggressive treatments that just end up prolonging the dying process. It can hurt physicians, who end up feeling burnt out, and the healthcare system, which bears the cost of end-of-life care. So if it’s that important, then why are these conversations so hard to start?

Why is prognostication hard?

Margot: There are a lot of challenges clinicians face in delivering prognosis. Dr. Smith shared a particularly humanizing story with us that illustrated his first point: communication is tricky, and clinicians need training in it like they would any other skill.

Smith: So when I was in residency, I was caring for this woman in her mid seventies, uh, who’d had regular mammography, uh, for years, decades, right. And I had just read Louise Walter’s seminal paper in JAMA about individualizing cancer screening, cancer screening decisions in the elderly. And she argues that rather than using sort of arbitrary age based cutoffs, we should be individualizing decisions about whether to continue or stop screening in older adults based on their prognosis. And this particular woman because of her function and because of her comorbid conditions and her age, um, did not seem, it did not seem like she would, uh, continue to benefit from mammography to screen for breast cancer. So I being, you know, sort of a naive resident went in the room and I, you know, outpatient primary care clinic, I said to her, you know, good news, you don’t need to be screened for breast cancer anymore, we can stop the mammograms. And she said, why not, I’ve been getting these for decades?  And I said, you’re unlikely to live long enough to benefit. And I could feel the temperature in the room just dropped. And I realized I had, you know, stuck my foot in my mouth and I had no idea what I was doing in terms of communicating prognosis. Um, so that really got me thinking, you know, as much as the science of estimating prognosis is challenging, the art of communicating prognosis is also challenging and is this skill that you can develop. And there are better ways to do that, and there are worse ways to do that.

Margot: The second problem is that we’re often working with incomplete information. Dr Smith shared a story of a patient he cared for, a gentleman who was elderly, pretty frail, who was hospitalized and found to have a metastatic cancer of unknown origin. They didn’t have a tissue diagnosis at the time of the family meeting, and the son asked the question on everyone’s mind: how long did the patient have to live?

Smith: So this was, you know, a challenge, and most oncologists might just defer prognostication entirely because they’re so used to prognosticating based on the disease itself.  You know, in trials of people with X condition, this is what happens. We didn’t know that. But in his case, because of his advanced state of disability, because of his advanced age, because he had other chronic conditions, we were able to estimate for him that he likely had a prognosis on the order of weeks, and maybe a few months, but months on one hand. And that was helpful information to the patient and to his son as they went about planning for their financial future.

Tamar: And while this was a win for this patient without a known diagnosis, even when we do know what disease a patient has, that alone does not give us the whole answer to prognostication. Often specialists look to disease-specific clinical trials to guide prognosis, but this data usually comes from younger, healthier patients than the individual patient sitting across from me, now. This data can also be outdated as improved treatments become standard of practice and supportive care has improved. 

Smith: This will likely resonate with many of your clinicians, when they get an estimate of prognosis from an oncologist. Often we’re like, huh, that doesn’t really sit with what I’m seeing, you know?  And that’s because the oncologists — if they’re relying exclusively on that prognostic disease-specific index — are likely overestimating the patient’s prognosis because they’re not seeing the complete patient. You know, the patient has dementia, that patient is in bed most of the time and eating very little. Those factors are not well captured in these studies that go into these, you know, single disease, prognostic indices.

Jafar:  So while the science of creating an accurate prognostic estimate is fraught with difficulties, even when we feel we do have a clear view of a patient’s prognosis, there are still a lot of factors that hold us back from saying it.  What if the patient isn’t emotionally prepared to hear their prognosis? Am I taking away their hope? Actually, studies that have described patient reflections from  prognostic disclosures actually cited no harm to their emotional state or the doctor-patient relationship because of that conversation.  Again, most want their doctor to be realistic and honest with them.

Tamar: Another way to phrase this hurdle you’re describing, Jafar, is that this topic is emotionally intense, and that’s just something we can be tempted to avoid.

Smith: These conversations are really often highly emotional.  And one of the key components of an effective conversation is being able to respond to emotion. James Tulsky has done some work, looking at, you know, physicians who care for people with serious illness, primarily in cancer but also in other conditions. And he’s tape recorded their conversations, in clinic and other settings. And what he’s found is that when patients make highly emotional statements, clinicians, our tendency is often to terminate the conversation, and to move off in a different direction. And what he and his colleagues and others have suggested is that that’s a real disservice to patients, and that we need to do a better job of acknowledging that emotion, and bringing it out in conversation, so that we can help patients work through it. So we can understand their inner lived experience.

Margot: To wrap up this section on challenges, I want to share a story about a challenging case I had, one which has made me hesitant to start these conversations. There was a patient I cared for in the ICU whose heart and kidneys were failing, and who had underlying dementia – all diagnoses that take a huge toll on length and quality of life. I had a 27 hour call one night where I spent an hour or two talking with the daughter. I wanted to communicate honestly without taking away her hope, but that’s a difficult thing to do when you’re speaking with someone who can’t imagine letting go. I wanted to prepare the daughter for the possibility that her father wouldn’t survive this long hospitalization, but she wasn’t ready to hear it. The patient ended up pulling through, and I lost track of him when he was discharged from the hospital. A year later, I was walking past the dialysis unit when the daughter ran up to me. “He’s doing great!” she said – and while I was so glad he’d had a good outcome, part of me wondered whether I’d put her through all that stress for nothing. I definitely became more cautious about starting conversations about prognosis after that. 

Smith: So I would say that one of the reasons that clinicians often avoid prognostication is the chagrin factor. You know, they told a patient they were going to live X long amount of time, and they ended up exceeding that, you know, dramatically. And so they feel burned, so to speak, and they act on their last bad experience. There is a tremendous amount of uncertainty because of the heterogeneity in the patients who we’re seeing.  There are individual responses to illness or to treatment. Because we study populations of patients and we are talking about the individual in front of us, and as you say, there’s a bell curve of a distribution. And as one person famously put it, the median is not the message, right? You need to individualize that curve further for the patient in front of you, and even when you do that there’s still quite a bit of uncertainty around it.

How do we improve it?

Jafar: Wow, ok so this is a pretty difficult task to take on, but as we’ve pointed out there are a host of good reasons why we should step up to the plate.  So the next obvious question is: how do we get better at it?

We’ll divide the answer into two parts: first, the science of creating a more accurate prognostic estimate, and second, the art of communicating it effectively to patients.  To start with the first point, despite all the limitations we’ve pointed out with them, it is still a best practice to at least start with a prognostic index relevant to the patient in front of you–and there may be more than one.  Prognostic calculators exist for many major life-limiting illnesses, including heart failure, COPD, chronic kidney disease, and almost every malignancy. Check out the show notes for links to some of the bigger ones.  

Margot: But what if the patient has more than one major medical problem, and doesn’t really fit into any specific calculator? There are a few more holistic calculators, which focus on a big picture view of the patient rather than one specific disease. The first one we want to talk about is Walter’s Prognostic Index, which is aimed at predicting one-year mortality for hospitalized patients over 70 years old who are about to leave the hospital. The second is the Palliative Performance Scale, which is meant to predict the three-month mortality of patients with advanced cancers or who are enrolled in hospice.  Both share a focus on basic functioning – how much is the patient eating? Can they walk? Do they need help getting dressed or bathing? These simple questions are powerful predictors of prognosis. 

Jafar: But if you’re starting to get overwhelmed with too many tools and numbers and caveats–don’t panic! Our guest for this episode has invested a lot of time in tackling this for you.  Well, not JUST him:  

Smith: So in 2009-2010, a UCSFs medical student named Lindsay Yourman took a year off to do research with me and I gave her this book by Nicholas Christakis, called “Death Foretold:  Prophecy and Prognosis,” and she read it, loved it, and got really excited about this issue of prognosis. How can we incorporate prognosis in everyday decision-making? So we worked together and conducted a systematic review of prognostic indices for older adults. It’s just sort of general prognostic indices for older adults, not disease specific, and sent it to JAMA and eventually they accepted it. So we told Lindsey, um, congratulations, you’re a med student and you have a first author publication in JAMA, you’ve won the game. And Lindsay said, that’s not actually what I want to do. I actually want to change practice. I want people to use prognostic indices. So we developed ePrognosis, which is a compendium of multiple prognostic indices for older adults. Uh, and it’s E we made, it is our, Our mantra is trying to make these prognostic tools easy for clinicians to use.  So we have prognostic indices that are for the inpatient setting, we have prognostic indices that are for the outpatient setting, and we have prognostic indices that are for the nursing home setting.

Tamar: So inspirational that Lindsay had such a large role in helping develop ePrognosis during medical school. These tools and indices are an important first step because they help us stay objective. We have lots of biases when it comes to our patients, and, as it turns out, these biases lead us to overestimate survival. Nicholas Christakis and his colleagues have published a number of papers on this. In one paper, over 300 physicians studied were accurate with their prognosis for hospice patients less than 20% of the time, and most predictions overestimated survival by a factor of about 5. But it gets even more interesting…

Smith: The second interesting wrinkle is that the longer the clinician knew the patient, the more likely they were to make an error in prognostication, usually on the optimistic side. I think that’s an important lesson too, that we grow to bond, you know, we bond with our patients. We hope for the best for them, with them.  And the longer we have that relationship, unfortunately, the more biased we tend to be in our formulating a prognostic estimate. So sometimes people tell me, you know, we should go to the primary care doc because they know the patients best–and they do know the patient’s best! That is absolutely right. On the other hand, they may be at risk of the bias of, you know, hoping with their patients that they may have longer to live than their empirical evidence would otherwise suggest. 

Margot: While our empathy might be our Achilles heel, we don’t want you walking away thinking that physician estimates don’t matter. The 1995 SUPPORT trial found that the most accurate models incorporated physician’s assessment along with objective data like age and diagnosis. 

Jafar:  And these survival estimates get even stronger when we average the input from multiple clinicians.  A study found that using resident and fellow prognostic estimates together predicted survival in the ICU better than either of them alone.  Moreover, using this average created an estimate that was even more accurate than their attending’s solo judgment.  Trainees, unite and conquer! So phone a friend, use a prognostic calculator–we should use all the tools we have.

How should we approach uncertainty?

Tamar: So all these tools make it easier to estimate lifespan, but this still leaves an elephant in the room that we felt should be addressed here, and that’s the fact that there will always be uncertainty in predicting prognosis. So how should we approach and manage this uncertainty? Firstly, don’t let it scare you out of having these conversations. 

Smith: I guess the first lesson where we’re talking about uncertainty is don’t hide behind uncertainty, don’t use the uncertainty as either an excuse not to discuss prognosis, because it’s uncomfortable for you, it’s emotional, et cetera. And don’t use it at the uncertainty as an excuse to give them a wildly optimistic prognosis.

Jafar:  And as I was mentioning before, clinical clarity is almost always improved with the input of others:

Smith: I manage, operationally, I manage that uncertainty by talking with other clinicians, uh, openly about it and trying to, you know, see, you know, reflecting with them about their experiences of uncertainty where the patients who we’re caring for.  And together we can often, you know, develop a fuller picture of the patient’s prognosis so that we can give them a more accurate estimate, and we feel more comfortable ourselves that we’ve considered multiple aspects of that patient’s prognosis, not just say one disease or one lab test.

Margot: I would say, though, that it’s important to hash out everyone’s different opinions before walking into the patient’s room. Dr. Smith recommended having a pre-meeting before the family meeting. 

Smith: In palliative care, our procedure is the family meeting, right? The cardiologists have their caths and the nephrologists just have the dialysis. We’ve got the family meeting and when I’m teaching about how to have a family meeting, one of the things I tell my trainees is the pre meeting that you have before the family meeting is as important or more important than the family meeting itself. Why? Because it’s the opportunity for all of these clinicians to get on the same page. And one of the key components that needs to be addressed before every family meeting is what they think the patient’s prognosis is.

Tamar: And it’s also crucial to remember that prognostic uncertainty causes distress for us as clinicians, but it’s doubly so for patients, which should motivate us to try to offer them some clarity, even if these conversations are imperfect. And it’s good to acknowledge your uncertainty.

Smith: Like I say to patients, I could pick a date and I guarantee I’d be wrong. Right? I’m acknowledging uncertainty upfront. No one knows for sure. Right? And yet, because we have seen many patients like you and because we have information, medical knowledge from studies about other patients like with you, we can give you an idea. Um, is that something that you’d be interested in talking about? So normalizing the uncertainty, right? I wish we had more information, this is what we have.

Jafar: There is also evidence to suggest that most patients and surrogates already appreciate the uncertainty inherent to prognostication.  A study that reviewed interviews with surrogates in the ICU, found that 87% said they would want to discuss prognosis even in the face of uncertainty, and that honesty about uncertainty actually built more trust with their physicians.  Overall, I found this reassuring, and even liberating, to hear that it’s ok in these discussions to sometimes say “I don’t know.” Because frankly there’s a lot we don’t know, or can’t know.

Tamar: That’s also why we should offer prognosis with a range of time that recognizes that there is uncertainty, like saying  “days to weeks” or “weeks to months.” Dr. Smith also suggested another method that uses really useful, plain language when comparing treatment choices. 

Smith: Another technique that’s really coming into favor is called the best case, worst case, most likely case. And that’s something that’s particularly useful when you are comparing two treatment options. You know, like with uh, chemotherapy and radiation. The best case for you would be that the chemotherapy is effective at controlling your symptoms, that you don’t have a poor reaction to the chemotherapy or the radiation, and you’re able to be functional and spend time with your family.  And the worst cases, the treatment actually is more harmful to you than it is helpful. You get an infection because of the chemotherapy, and it’s depressing your immune system. The most likely case is there’ll be good days and bad days, and they’ll be really hard up front when you have the chemotherapy and radiation. But overall over time you, you probably have some benefit from it and have fewer symptoms.

Communication tips

Margot: There is one caveat – patients and family members don’t take clinicians’ estimates as the final word.

Smith: Just because we’ve guessed, estimated prognosis and communicated to the patient does not mean they believe it. There are other things they rely on, you know.  They don’t realize the strengths and inner resources this patient has and you know, my loved one has or you know, they’ve been through so much or religious resources or you know, faith in a higher power.  So that our prognostic estimates are, you know, when we communicate to the patients, we need to check in with them and see where they are and what they think the prognosis is even after we’ve communicated it to them. Cause it may still be wildly different from what we estimate.

Jafar:  To me, this means that if I want to have a productive and honest conversation about life expectancy with a patient or their surrogates, I need to first understand what their reasoning structure looks like, so I can meaningfully add to it.  If I try and steamroll or ignore it, I’m less likely to be able to address mistaken beliefs than if I came to it from a place of curiosity and respect. As Teddy Roosevelt famously put it: “People don’t care what you know until they know that you care.”

Margot: I personally have a bad habit of jumping right into heavy conversation, both in medicine and in life. One thing I’m working on is asking how patients want to communicate, before I start, you know, trying to communicate with them. Here are a few questions I’ve been trying to incorporate: Can we talk about the results of your scan? Do you want a friend in the room? Would you rather be alone? Would you  prefer that information go through a family member? Giving patients control makes it more likely that they’ll hear and retain information, and you’ll be less likely to overwhelm them with news they weren’t ready for. Dr Smith also recommends that you ease into the conversation by first asking a patient what they think their prognosis is.

Smith: Before I say what my prognostic estimate is, could you tell me a little bit more about what you think it might be? Right. So you have some sense of where they are.  So you have like a structured approach to having these conversations. And then, well, you know, based on what you said, I think you’re in the right ballpark, but it might be a little bit shorter than what you’re thinking. You know, it’s probably this sort of range in here.  And then how do you react to that information? You know, what’s going on for you? Is that, you know, is it hard for you to hear that cause it wasn’t exactly what you were expecting. So reacting to that emotion and trying to bring it out.

Tamar: And importantly, when your patients are the ones asking to discuss prognosis, make sure you try to understand why they’re asking. Is it because you are thinking about moving in with your daughter for help? Are you hoping to live another three months to be around for your grandchild’s birth? Knowing an individual patient’s priorities can help tailor medical decisions. 

Jafar: Finally, we wanted to emphasize just a few basic communication tips.  We know how medically complex these topics can be, and it’s easy to get lost in the weeds trying to address uncertainty by getting into all the medical details.  Try and stick with plain language first: avoid medical jargon wherever possible, and if they ask, then you can go into more detail. 

Using language that reflects what the patient themselves are telling you can be particularly effective.  Some palliative folks I’ve worked with describe this as using “Hope-Worry” statements. For example, “I really hope you can see your daughter graduate from college next year, and we will work toward that goal. I also worry that may not be possible if you get sicker.”  When breaking bad news about a more limited prognosis, using so called “Wish” statements can also work to align you with that person in front of you; for example, “I wish we had more effective treatments for you.” Be especially aware of avoiding euphemisms. Don’t say “pass” or “expire”; instead just come out and say “death” or “dying process.” 

Overall, communication around these topics can be complex, and in the heat of the moment it’s very easy to forget all of the suggestions mentioned here.  To keep myself organized, I find it’s always best to use a structured approach, following an acronym like SPIKES or ADAPT to make sure I’m exploring patient perceptions and preferences first, then discussing my relevant prognosis, responding to emotions, allowing for silence, and synthesizing in a way that uses teach-back methods to ensure mutual clarity.   A helpful app that I use for this is called VitalTips, which includes a lot of communication tips, acronyms, and references to relevant literature. 

Conclusion

Tamar: We want to wrap up this episode by summarizing some of the useful takeaways. Again, we’re so thankful to Dr. Smith for helping us maneuver through the importance of prognosis, the science behind these estimations, and the art of delivering them. So firstly, as we mentioned, there are many tools available; we hope you head over to our show notes to check them out. The easiest and most comprehensive one for us was E-prognosis. Play around with these calculators and think about how they can be useful in your practice. 

Margot: Remember to recruit expert opinion when possible, since disease-specific factors often play a big role. But since everyone may have a different perspective, remember to balance multiple estimates and keep the overall view of the patient in mind.

Jafar: Lastly, studies show that patients want and benefit from discussions of prognosis.  Some patients may not be ready to talk about it, we should at least open it up – even if uncertain – because other clinicians may not.  It’s not easy, but deliberate practice can definitely make us better:

Smith: And so it’s important to gain skills and offering to talk about that with patients. Not forcing it on them, but offering to talk about the prognosis, responding to questions they might have, acknowledging the uncertainty inherent in prognosis, but not hiding behind it, and responding to the emotional content of those discussions. 

Jafar: Thanks for tuning in!  We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences and reflections on prognostication. Please continue the conversation with us online at our facebook page, on twitter, or email us directly.   Find show notes and contact information for us on our website: www.coreimpodcast.com/contact/

If you enjoyed listening to our show, give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you.  Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions. 

Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Julia Skubisz, our illustrator Michael Shen, endless technical support from Harit Shah,  and most importantly thanks to you, our listeners!

References

 

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