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Physician Estimates of Prognosis
Physicians are routinely asked to make estimates of patient survival. In providing such estimates, physicians undertake two separate tasks: (1) they formulate a prognosis, or make a mental calculation of the patient's expected survival, and (2) they communicate the prognosis to the inquiring individual, often a patient or the patient's family. The survival estimates, or prognoses, that physicians formulate and then communicate are important to both physicians and patients in all phases of a patient's life because they guide both medical and nonmedical decisions. At the end of life, these prognoses can become critically important, as they may signal a change from primarily curative or life-prolonging care to primarily supportive or palliative care, a change that clearly influences clinical and personal decisions. Ironically, physician prognostication is often inaccurate, both in terms of the prognoses physicians formulate and in terms of the prognoses physicians communicate to patients or their families.
Importance of Prospective Identification of the End of Life
There is wide agreement among patients, their families, and doctors that the “end of life” is an important period to recognize prospectively because, among other things, the type of medical care that patients receive during this period should be different than that which they receive at other points in their life. Specifically, there is agreement that the medical care should be supportive in nature, focused on the control of symptoms such as pain, rather than invasive in nature, and aimed at extending life. Consistent with this approach, most agree that the favored place of death is the home rather than the hospital. Most physicians report that such home-based, symptom-guided care should be initiated at least 3 months prior to patient death for optimal palliative care.
Despite fairly broad agreement that home-based, symptom-guided care is the preferred form of medical care at the end of life, epidemiologic and health services research reveals that the current patterns of medical care for those dying in America are far from this ideal. For example, a study of Medicare claims data (an excellent population-level source of medical treatment and survival data for elderly Americans) shows that about half of all Medicare beneficiaries die in acute-care hospitals rather than in their homes. Furthermore, fewer than 20% receive hospice care, the most common route to home-based, symptom-guided therapy, prior to death. Finally, of the few who receive this idealized form of medical care at the end of life, most receive it for a period far shorter than the idealized 3 months, generally less than 1 month prior to death. The same work reports that fewer than 15% of Medicare beneficiaries enrolled in hospice programs survive longer than the allotted 6 months.
Inaccuracy of the Formulated Prognosis
While physician prognostication is largely an understudied aspect of clinical medicine, there are studies in the palliative care literature and in the clinical oncology literature that suggest physicians are generally inaccurate in estimating patient survival (i.e., prognosis). Specifically, in the palliative care literature, there are several studies specifically designed to determine the quality of physicians' formulated prognoses in patients with advanced illness. These studies report quality in the form of physicians' prognostic accuracy in predicting survival of patients following admission to hospice programs. Investigators in these studies have measured physicians' prognostic accuracy by comparing patients' observed survival with their predicted survival (these predictions are not necessarily those communicated to patients; rather, they are the ones physicians formulate for themselves). Results of these studies show that, in aggregate, physicians' overall survival estimates tend to be incorrect by a factor of approximately 3, always in the optimistic direction. A representative study documents that physicians overestimate patient survival by a factor of 5 and patients, on average, live only 24 days in hospice.
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