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29-12-2011 | Article

Prognostication in palliative care ‘lacks evidence’


Free abstract

MedWire News: A number of difficulties are associated with prognosticating for palliative care patients, say hospital specialists.

"Available [evidence] indicates that professionals are frequently asked to prognosticate regardless of their experience, that it is an understated part of their everyday work and is a complex, emotive subject," explain study authors David Pontin (University of Glamorgan, Pontypridd, UK) and Nikki Jordan (North Bristol NHS Trust, UK).

The qualitative research, published in the journal Palliative Medicine, explores how palliative care specialists approach prognostication and their views on the subject.

Focus groups were held at three UK hospitals, each composed of a maximum of eight specialist palliative doctors and nurses. A question guide was used but open questions encouraged the participants to express their views in their own words, state the researchers.

The participants perceived several benefits to prognostication including the ability to make patient-informed decisions and enabling the patients and their families to make plans.

The main topics that appeared to present difficulties for the health professionals were the elements to consider when making a prognosis, the prognostic model to employ, and concern over the accuracy of their prognosis.

The participants said there were measurable factors that help them make a prognosis such as blood tests, knowledge of cancer stage, disease progression rate, and symptom burden. Although being able to assess patients over a longer period of time made prognosis easier, this often was not possible due to the pressure to discharge patients.

The participants also pointed out that a degree of intuition was involved. "When the evidence is contrary to gut instincts those are the really difficult ones…you can tell that they have got a progressive disease but they haven't found it yet, or imaged it yet," said one participant.

Confidence and accuracy of prognoses were issues that the health professionals found difficult, especially when patients ask them to give a specific time frame. For example one participant said: "I still won't mention numbers and I still will talk about short weeks, or long weeks, I just won't let them tie me down to numbers because I know what happens: they circle it on the calendar."

The authors say that the main strength of this research is the insight it provides into health professionals' views. However, they conclude: "Further research in the UK and elsewhere is required to deepen our understanding of the processes leading to clinical prediction… and to determine whether accurate prognostication and timely communication improves decision-making and outcomes for palliative patients at the end of life."

By Chloe McIvor