Defining the Scope of Prognosis: Primary Care Clinicians' Perspectives on Predicting the Future Health of Older Adults

Thomas, John M.; Fried, Terri R.

doi:10.1016/j.jpainsymman.2018.01.017

Cited by 8 publications

(27 citation statements)

References 27 publications

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“…3 This view is supported by 2 qualitative studies, in which clinicians expressed a number of reservations about the use of explicit mortality risk and life expectancy estimates in clinical practice; these concerns included the limited accuracy of the predictions themselves, and the possibility that patients will not receive the information well if discussed. 1,2 Some modern authors have made a point to distinguish the concepts of "foreseeing" and "foretelling," as conveyed in the Hippocratic definition of prognosis, to differentiate between the predictions physicians generate and the predictions they communicate to patients. 27,30 However, by way of comparison, such a distinction had little apparent relevance in the time of Hippocrates.…”

Section: The Decline (And Reemergence) Of Prognosismentioning

confidence: 99%

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confidence: 99%

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Prognosis Reconsidered in Light of Ancient Insights—From Hippocrates to Modern Medicine

2019

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lthough most clinicians would agree that knowledge about expected health outcomes is important for screening and treatment decisions, planning for the future, and goals of care discussions, they are often reluctant to discuss prognosis with their patients. [1][2][3][4][5] This hesitancy is particularly characteristic of modern medicine. In ancient Greece, prognostic discussions were central to medical practice. [6][7][8] What are the reasons for this difference in the prognostic practices of ancient and modern clinicians? A historical analysis has the potential to answer this question and to provide insights into overcoming current challenges in prognosis.

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Section: The Decline (And Reemergence) Of Prognosismentioning

confidence: 99%

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confidence: 99%

Prognosis Reconsidered in Light of Ancient Insights—From Hippocrates to Modern Medicine

2019

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“…In two qualitative studies, primary care clinicians described several factors that influence their own perception of patients' trajectories, but expressed little familiarity or comfort with using validated prognostic indices. 65,66 Evidence suggests that clinicians' ability to prognosticate is poor; estimates vary particularly when patients have longer predicted life expectancies. 67,68 Several prognostic indices have been developed and validated for predicting mortality in older adults.…”

Section: What Is the Patient's Likely Health Trajectory?mentioning

confidence: 99%

“…Given the priority many older adults place on outcomes other than death, prognostication of other outcomes is also important in clinical decision-making. 66 However, there are few tools to predict the probability of multiple competing outcomes. A promising methodology has recently been proposed by Allore and colleagues to calculate the absolute risk of several competing outcomes in older adults with MCCs.…”

Section: What Is the Patient's Likely Health Trajectory?mentioning

confidence: 99%

Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions

Ouellet

Tinetti

2018

Therapeutic Advances in Drug Safety

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Although the majority of older adults in the developed world live with multiple chronic conditions (MCCs), the task of selecting optimal treatment regimens is still fraught with difficulty. Older adults with MCCs may derive less benefit from prescribed medications than healthier patients as a result of the competing risk of several possible outcomes including, but not limited to, death before a benefit can be accrued. In addition, these patients may be at increased risk of medication-related harms in the form of adverse effects and significant burdens of treatment. At present, the balance of these benefits and harms is often uncertain, given that older adults with MCCs are often excluded from clinical trials. In this review, we propose a framework to consider patients' own priorities to achieve optimal treatment regimens. To begin, the practicing clinician needs information on the patient's goals, what the patient is willing and able to do to achieve these goals, an estimate of the patient's clinical trajectory, and what the patient is actually taking. We then describe how to integrate this information to understand what matters most to the patient in the context of an array of potential tradeoffs. Finally, we propose conducting serial therapeutic trials of prescribing and deprescribing, with success measured as progress towards the patient's own health outcome goals. The process described in this manuscript is truly an iterative process, which should be repeated regularly to account for changes in the patient's priorities and clinical status. With this process, we aim to achieve optimal prescribing, that is, treatment regimens that maximize benefits that matter to the patient and minimize burdens and potential harms.

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“…However, patients do not understand why their PCP would discuss their life expectancy when discussing stopping screening 5 . PCPs find estimates of patient life expectancy helpful when making screening recommendations but feel uncomfortable discussing patient life expectancy for fear of upsetting patients 6–9 …”

Section: Introductionmentioning

confidence: 99%

Strategies for discussing long‐term prognosis when deciding on cancer screening for adults over age 75

Jindal

Karamourtopoulos

Jacobson

et al. 2022

J American Geriatrics Society

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Background: Consideration of older adults' 10-year prognosis is necessary for high-quality cancer screening decisions. However, few primary care providers (PCPs) discuss long-term (10-year) prognosis with older adults.Methods: To learn PCPs' and older adults' perspectives on and to develop strategies for discussing long-term prognosis in the context of cancer screening decisions, we conducted qualitative individual interviews with adults 76-89 and focus groups or individual interviews with PCPs. We recruited participants from 4 community and 2 academic Boston-area practices and completed a thematic analysis of participant responses to open-ended questions on discussing long-term prognosis.Results: Forty-five PCPs (21 community-based) participated in 7 focus groups or 7 individual interviews. Thirty patients participated; 19 (63%) were female, 13 (43%) were non-Hispanic Black, and 13 (43%) were non-Hispanic white.Patients and PCPs had varying views on the utility of discussing long-term prognosis. "For some patients and for some families having this information is really helpful," (PCP participant). Some participants felt that prognostic information could be helpful for future planning, whereas others thought the information could be anxiety-provoking or of "no value" because death is unpredictable; still others were unsure about the value of these discussions. Patients often described thinking about their own prognosis. Yet, PCPs described feeling uncomfortable with these conversations. Patients recommended that discussion of long-term prognosis be anchored to clinical decisions, that information be provided on how this information may be useful, and that patient interest in prognosis be assessed before prognostic information is offered. PCPs recommended that scripts be brief. These recommendations were used to develop example scripts to guide these conversations. Conclusions: We developed scripts and strategies for PCPs to introduce the topic of long-term prognosis with older adults and to provide numerical prognostic information to those interested. Future studies will need to test the effect of these strategies in practice.

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Defining the Scope of Prognosis: Primary Care Clinicians' Perspectives on Predicting the Future Health of Older Adults

Abstract: The perspectives of primary care clinicians in this study confirm that prognostic considerations can go beyond precise estimates of mortality risk and life expectancy to include a number of outcomes and approaches to predicting those outcomes.

Cited by 8 publications

References 27 publications

Prognosis Reconsidered in Light of Ancient Insights—From Hippocrates to Modern Medicine

Prognosis Reconsidered in Light of Ancient Insights—From Hippocrates to Modern Medicine

Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions

Strategies for discussing long‐term prognosis when deciding on cancer screening for adults over age 75

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