Discussing Prognosis

Abstract

"How much time do I have?" A patient's question about his/her life expectancy is among the most difficult of conversation topics. Oncologists, often with very little training in communication, routinely handle these requests for sensitive information. Oncologists are aware of the emotional weight surrounding a prognosis discussion: answering a prognosis question poorly can damage both a patient's sense of hope and the relationship with his/her physician. Conversely, when handled well, the discussion can affirm the relationship, build trust, and leave the patient feeling hopeful. Our review presents clinicians with a practical approach to handling prognosis discussions by dealing with 4 critical issues. First, we review what information should be conveyed about a patient's prognosis. Next, we provide tools to help the oncologist deal with a patient's emotional reaction. Then, we provide a framework for the discussion that helps preserve a patient's hope despite a poor prognosis. Finally, we address the impact on the physician and provide some suggestions for dealing with our own emotional reactions.

Conveying hope in consultations with patients with life-threatening diseases: the balance between supporting and challenging the patient

“…In such research, a recurring result is that patients with cancer want honest and complete information [6–10]. Both the majority of patients with early stage cancer [8] and patients with metastatic cancer [9] considered individualised and realistic disclosure from a confident, collaborative, supportive cancer specialist to be more hopeful than avoidance.…”

“…The aspects of communication that patients have most valued are those that help them and their families to feel guided, that build trust, and that support hope [13]. Patients report being supported by clinicians who empathically respond to their emotions [6]: ‘Silence can “speak” loudly to tell the patients that the doctor is comfortable with them taking their time’ [6]. …”

“…When asked about what they perceive as most important in consultation, especially when discussing a poor prognosis, both doctors and patients have emphasised conveying hope as essential [6,7,11]. At times, hope is attached with an offer of treatment [14,15]; however, both doctors and patients have emphasised the importance of hope independent of prognosis and treatment possibilities [6,7,11].…”

“…At times, hope is attached with an offer of treatment [14,15]; however, both doctors and patients have emphasised the importance of hope independent of prognosis and treatment possibilities [6,7,11]. In fact, patients seem able to maintain a strong sense of hope despite having accepted that their life expectancy is limited [11,16].…”

Complications from Stents and Lack of Conversations

“…These conversations cannot be left until the provider thinks that all treatment options have been exhausted as this patient developed an uncommon complication of the stent and did not survive long enough to receive systemic therapy for the tumor. A good article about how to discuss prognosis is available [9].…”