Tools to Improve the Communicated Prognosis

As with other challenging aspects of clinical medicine, algorithms may be useful for physicians in the challenging task of prognostic communication to patients. Many of these algorithms include those elements that patients say they want and need to make decisions about how they will spend their remaining time (Degner 1997, Davison 1995, Blanchard 1988, Wenrich 2001, Parker 2001, Kutner 1999). Several groups have outlined approaches to the successful disclosure of bad news (Ptacek 1996, Buckman 1992, Von Gunten 2000, Fischer 2000, Rabow 1999).

In one approach, the physician understands the encounter to include 4 temporally ordered components, each with its own, important communication tasks (Fischer 2000).

Four Elements for Physician / Patient Communication about Prognosis — Overview

Preparation
Content
Patient’s response
Close

Please see a video clip of an example scene:

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The following table contains a summary of the types of tasks that we and other clinicians believe are important aspects of each segment. They are based on prior research of patients’ information preferences in advanced cancer. Physician statements are also modeled.

Four Elements for Physician / Patient Communication about Prognosis — Details

Tasks

Model Script

Preparation

Research the patient’s condition to determine prognostic parameters with and without therapy, both “life-prolonging” and “palliative.”
Arrange meeting in private place with ample time, seating, tissues, and no interruptions from telephones, pagers or staff.
Alert the patient ahead of time that you need to discuss important aspects of his or her health. Suggest that the patient bring a person important in his or her life to the meeting. “The next time we meet, we will be reviewing important test results regarding your illness. I think it is important that you bring with you someone who is important to you.”
At the meeting, first establish how the patient is feeling, identifying symptoms that can be the later focus of discussion of palliative therapies. Establish current level of debilitation (i.e., performance status). “First, I’d like to find out how you are feeling right now.” “Do you have any pain or other symptoms from the illness?” “How are you spending your days?” “Are you able to wash up?” “Who’s doing the cooking and cleaning now?” “How much of the day do you think you are in bed or on the couch?”
Establish the patient’s understanding of his or her illness. Ask what the patient hopes you will be able to do. “I wonder what your current understanding of your illness is and what you hope we can do for you.”
Finally, establish what the patient wishes to know from you about their illness. “Some people want to know everything possible about their illness and others prefer to know very little. How much about your illness do you want to know from me today?”

Content

Tell the patient that you have bad news to share (“Give a warning shot”). “I am sorry to say that I have bad news to share today.”
State the news clearly, simply, and sensitively. “It appears that the cancer has spread to your bones, which means that it is no longer curable.”
Provide information in small amounts at a time.
Make optimistic statements that are truthful. “I am very hopeful that with medicine we can control your bone pain.”
Anchor the survival estimate you communicate in previously published data and modify it by the patient’s current clinical status. “On average, patients with stage IV gastric cancer live 4 months. One quarter of patients will live 1.5 months or less and one quarter live 8 months or more. While I do not know for sure where you are in that group, the fact that you are feeling so poorly right now and in bed most of the time makes me concerned that you may not live longer than the average 4 months.”

Patient’s Response

Acknowledge the patient’s affect and express empathy. “I can tell how very difficult it is for you to hear this bad news.”
Assure the patient of your continued involvement in his or her medical care. Squarely address the issue that forgoing chemotherapy does not create a therapeutic void; patients often conflate “doing something” with chemotherapy. “Although we cannot cure or shrink your cancer with chemotherapy, we certainly can continue to take care of you and treat you with medicines for any symptoms that the cancer may cause. There is always something that we can do to help you.”

Close

Summarize the new news sensitively and outline a short-term plan of care. “What we have discussed is that your cancer has progressed to involve your bones, which has caused the calcium in your blood to become dangerously high. What I recommend we do next is to focus on returning the calcium level to normal and strengthening the bone around the tumor by adding a new medicine that is given by vein every month. I recommend that you get the first dose today in our office.”
Arrange a follow-up visit (even if the patient is being referred for hospice care), since it is a tangible example of continued commitment to the patient.
Offer to discuss the news with people important to the patient who are not present.
Provide the patient with means of contacting you and your team in an emergency.
Source: Lamont EB, Christakis NA. Complexities in Prognostication in Advanced Cancer: “To Help Them Live Their Lives the Way They Want to.” JAMA, Jul 2003;290:98-104.
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