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Prognostication Project

This model for communication was developed by Dan Kruszelnicki, a recent graduate from Queen’s University School of Medicine. It is intended for use by Palliative Care Physicians for their patients.

Why research prognosis?

There are many reasons to research how physicians prognosticate in palliative care.

  • In some jurisdictions and institutions, palliative care or hospice care is provided only when a patient has a limited time to live; therefore, estimating survival helps to determine whether to admit a patient to the program. (16, 25 )
  • Families often want and need to have some idea when their loved one might die - for instance, to arrange time off work or to travel to visit a sick relative.
  • Patients often want to know how long they might have to live. When deciding how to spend the remainder of ones life, it may be helpful to know how much time may be left. (16)

How good are physicians at predicting survival?

In short: not very. Many studies have shown that physicians are inaccurate and tend to be overly optimistic when predicting survival for their patients. ( 2, 4, 6, 17, 20 ) Physician optimism is demonstrated below. Two studies showed that, when compared with actual survival, physician estimates were overly optimistic.

What tools are available for prognosis?

For more information on the models, click Prognostic Tools on the tool bar; for a detailed comparison between different models, click here.

There are a number of models and scales that physicians can use to predict survival. These are of varying quality and utility. In other areas of medicine there are predictive algorithms that are very useful, like the GCS, TNM staging and the Goldman criteria (12). In palliative care though, there are no formulas as good as these.

Why aren't these tools used more often?

There are several reasons why models that have been developed for Palliative Care are not used very often.

  • Models don’t factor in treatments that may be offered to the patient
  • There is often overfit (too many unique statistics applied to the testing population)
  • There is little consensus on which clinical/laboratory variable should be included
  • There are some clinical variables for which it is difficult to assign a number (23)

How will the research being done here help?

The impression is that palliative care physicians’ predictions are inaccurate and overly optimistic, but we’re not sure why. A survey conducted through the Palliative Care Medicine Program at Queen’s University was administered to all physicians who are members of the Canadian Society of Palliative Care Physicians. For more information about this research project view the publication link, survey used and supplemental tables and figures found on the main Prognostication webpage.

Prognostic Tools

On this page are the following documents in PDF format:

  1. Bozcuk H, Koyuncu E, Yildiz M et al. A simple and accurate prediction model to estimate the intrahospital mortality risk of hospitalised cancer patients. International Journal of Clinical Practice 2004;58(11): 1014-1019.
  2. Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ 2000;320: 469-472.
  3. Clayton JM, Butow PN, Tattersall MHN. When and How to Initiate Discussion About Prognosis and End-Of-Life Issues with Terminally Ill Patients. Journal of Pain and Symptom Management 2005; 30(2): 132-144
  4. Dilemmas and Opportunities. Inaccurate Predictions of Life Expectancy. Arch Intern Med 1988;148: 2537-2538.
  5. Esmail N, Walker M. How Good is Canadian Healthcare? 2006 Report; An International Comparison of Healthcare Systems. Fraser Institute Digital Publication, 2006. http://www.healthwatchusa.org/conference2009/esmail/Esnmail-HWUSA-091113.pdf
  6. Forster LE, Lynn J. Predicting Life Span for Applicants to Inpatient Hospice. Arch Intern Med 1988;148: 2540-2543.
  7. Hagerty RG, Butow PN, Ellis PM, Dimitry S, Tattersall MHN. Communicating prognosis in cancer care: a systematic review of the literature. Annals of Oncology 2005;16: 1005-1053
  8. Harrold J, Rickerson E, Carroll JT et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? Journal of Palliative Medicine 2005;8(3):503-509.
  9. Head B, Ritchie CS, Smoot TM. Prognostication in hospice care: can the palliative performance scale help? Journal of Palliative Medicine 2005;8(3):492-502.
  10. Knaus WA, Harrell FE, Jr., Lynn J et al. The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments. Annals of Internal Medicine 1995;122(3): 191-203.
  11. Lau F, Downing GM, Lesperance M, Shaw J, Kuziemsky C. Use of Palliative Performance Scale in end-of-life prognostication. Journal of Palliative Medicine 2006;9(5): 1066-1075.
  12.  Lamont EB. A Demographic and Prognostic Approach to Defining the End of Life. Journal of Palliative Medicine 2005;8(1): S12-S21.
  13.  Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA 2003;290(19): 2581-2587.
  14. Lynn J, Teno JM, Harrell FE. Accurate Prognostications of Death; Opportunities and Challenges for Clinicians. West J Med 1995;163: 250-257.
  15. Maltoni M, Nanni O, Pirovanco M et al. Successful Validation of the Palliative Prognostic Score in Terminally Ill Cancer Patients 1999;17(4): 240.
  16. Maltoni M, Pirovanco M, Nanni O et al. Prognostic Factors in Terminal Cancer Patients. European Journal of Palliative Care 1994;1(3): 122-125.
  17. Miller RJ. Predicting Survival in the Advanced Cancer Patient. Henry Ford Hospice Medicine Journal 1991;39(2): 81-83.
  18. Morita T, Tsunoda J, Inoue S, Chihara S. Validity of the palliative performance scale from a survival perspective. Journal of Pain & Symptom Management 1999;18(1): 2-3.
  19. Olajide O, Hanson L, Usher BM, Qaqish BF, Schwartz R, Bernard S. Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine 2007;10(1):111-117.
  20. Parkes CM. Accuracy of Predictions of Survival in Later Stages of Cancer. British Medical Journal 1972;2:29-31.
  21. Pirovano M, Maltoni M, Nanni O, et al: A New Palliative Prognostic Score: A First Step for the Staging of Terminally Ill Cancer Patients. Journal of Pain and Symptom Management 1999;17: 231.
  22. Randolph A, Buchner H, Richardson WS, et al. The Users’ Guides to the Medical Literature: Chapter 10, Prognosis. 2002;141-154.
  23. Reynolds T. Prognostic Models Abound, but How Useful Are They? Annals of Internal Medicine 2001;135(6): 473-476.
  24. Stambler N, Charatan M, Cedarbaum JM. Prognostic Indicators of Survival in ALS. Neurology 1998; 50: 66-72.
  25. Toscani F, Brunelli C, Miccinesi G et al. Predicting survival in terminal cancer patients: clinical observation or quality-of-life evaluation? 2005;19: 220-227.

Overview

Survey of Palliative Care Physicians

Little is known about how and why physicians make the predictions they do when they prognosticate for their palliative care patients. Studies suggest that palliative care physicians are generally inaccurate, and tend to be overly optimistic, in their predictions of lifespan. The goal of this research is to better understand how and why physicians make the predictions they do. 
  
Study Reference

Corkum, M., Viola, R., Veenema, C., Kruszelnicki, D., Shadd, J. Prognositcating in palliative care: a survey of Canadian Palliative Care Physicians. Journal of Palliative Care. In press. Expected publishing date is June 2011.

Supplemental Materials

Study Questionnaire    
Supplementary Tables & Figures   

Contact Information

By Mail:
34 Barrie St
Kingston, Ontario, Canada
K7L 3J7

By Email:
rav@queensu.ca

By Telephone:
613.549.6666 ext 3223

By FAX:
613.548.2436