A Systematic Review of Predictions of Survival in Palliative Care: How Accurate Are Clinicians and Who Are the Experts?

Abstract

BackgroundPrognostic accuracy in palliative care is valued by patients, carers, and healthcare professionals. Previous reviews suggest clinicians are inaccurate at survival estimates, but have only reported the accuracy of estimates on patients with a cancer diagnosis.ObjectivesTo examine the accuracy of clinicians’ estimates of survival and to determine if any clinical profession is better at doing so than another.Data SourcesMEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews and Trials. All databases were searched from the start of the database up to June 2015. Reference lists of eligible articles were also checked.Eligibility CriteriaInclusion criteria: patients over 18, palliative population and setting, quantifiable estimate based on real patients, full publication written in English. Exclusion criteria: if the estimate was following an intervention, such as surgery, or the patient was artificially ventilated or in intensive care.Study Appraisal and Synthesis MethodsA quality assessment was completed with the QUIPS tool. Data on the reported accuracy of estimates and information about the clinicians were extracted. Studies were grouped by type of estimate: categorical (the clinician had a predetermined list of outcomes to choose from), continuous (open-ended estimate), or probabilistic (likelihood of surviving a particular time frame).Results4,642 records were identified; 42 studies fully met the review criteria. Wide variation was shown with categorical estimates (range 23% to 78%) and continuous estimates ranged between an underestimate of 86 days to an overestimate of 93 days. The four papers which used probabilistic estimates tended to show greater accuracy (c-statistics of 0.74–0.78). Information available about the clinicians providing the estimates was limited. Overall, there was no clear “expert” subgroup of clinicians identified.LimitationsHigh heterogeneity limited the analyses possible and prevented an overall accuracy being reported. Data were extracted using a standardised tool, by one reviewer, which could have introduced bias. Devising search terms for prognostic studies is challenging. Every attempt was made to devise search terms that were sufficiently sensitive to detect all prognostic studies; however, it remains possible that some studies were not identified.ConclusionStudies of prognostic accuracy in palliative care are heterogeneous, but the evidence suggests that clinicians’ predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other.Implications of Key FindingsFurther research is needed to understand how clinical predictions are formulated and how their accuracy can be improved.

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“…Several studies have shown that clinicians are generally over optimistic in their estimates of the prognoses of terminally ill patients [9] [5] [10] [11]. It has also been shown that no subset of clinicians are better at late stage prognostication than than others [12] [13] . However, clinician judgment remains the most common method of predicting survival in practice [12].…”

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“…Accurate prognosis is consistently shown to be important to patients, caretakers, and physicians from both a clinical decision standpoint but also an emotional standpoint (White et al, ). Cases like those described here are particularly concerning because physicians who overpredict early lethality have been shown to provide less resuscitation in the neonatal ICU potentially indicating that a poor prognosis can become a self‐fulfilling prophecy (Medlock et al, ).…”

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“…[4][5][6] These wishes cannot be fulfilled if the clinical team are not able to recognise accurately that the person is dying. Although clinician predictions of survival are frequently inaccurate and overoptimistic, [7][8][9] they are still quite well correlated with actual survival and so are still recommended for use in routine clinical practice. 10 The 'More Care: Less Pathway' report into the limitations of the Liverpool Care Pathway (LCP) described, among other things, the dissatisfaction of relatives with the information they were given about how long their relative was expected to live.…”