Predicting death – No Way!

Posted by: admin on: May 3, 2012

Poor clinical decisions due to wrong prognostic views have affected our medical treatment and management. It is high time we had a guideline towards judging the prognosis.


Slender, in her 60s and possessing the stoicism of someone who had single-handedly raised children in the toughest section of the city, our patient faced a difficult challenge of the medical kind. She had diabetes and such severe peripheral vascular disease that even the strongest antibiotics could not heal a long-standing foot infection. She needed an operation.
A week after her bypass operation, our patient died of a heart attack. The prognosis of her senior surgeon and our entire team — that she would tolerate the surgery and survive long enough to walk again — had been incorrect.
While not all assessments of how long someone has to live result in life-or-death clinical decisions, addressing prognosis remains a challenge for most doctors. And after struggling for several years with determining their own patients’ prognoses, a group of physicians at the University of California in San Francisco set out to collect and study all the research that had been done on so-called prognostic indexes, tools that help with determining general prognosis in older patients.
Given the growing use of age-based treatment and preventive care guidelines, the doctors assumed there would be plenty of data to help decide whether, for example, an 80-year-old patient might live long enough to benefit from a colonoscopy, a cancer screening procedure that can have its own set of complications.
But they found little.
While the researchers were finally able to single out 16 indexes that hold promise in helping doctors predict how long a patient might live, there was “insufficient evidence at this time” to recommend any of them for widespread clinical use. None of the indexes had been tried with groups of individuals other than the initial test group to confirm reliability, and every single one had a potential source of bias. “There’s a need for much more research in this area,” said Dr. Eric W. Widera, one of the authors of the study, A century ago, predicting a patient’s life expectancy was an essential part of doctoring. Details relating to the art and science of “prognosticating” occupied a prominent position in textbooks, journals and conversations with patients. That emphasis began to shift as technology advanced, with doctors focusing more and more of their time on treatment and diagnosis.
Perhaps even more important, prognosis has now become a potent symbol of the limits of medicine. With a growing array of successful treatments at hand, doctors often have the power to forestall death. But thinking about prognoses means recognizing not only fallibility but also possible culpability.
With so little research on how to predict how long a patient might live and few resources to turn to, physicians often end up relying on intuition. But studies have shown that these “guesstimates” can be wildly inaccurate, and that inaccuracy can adversely affect an older patient’s quality of life and care. Doctors who are too optimistic may prescribe unnecessary and painful procedures and treatments; those who are too pessimistic may neglect to offer adequate care.
While the authors of the study have created a Web site,, to help physicians and patients access available prognostic tools, they are quick to acknowledge that this interactive tool is only a small part of what doctors and patients need. More work and resources must be devoted to creating accurate assessment tools, testing the reliability of those that exist and teaching doctors once again the art and science of determining, and talking about, prognoses.
“We actually have a moral responsibility to our patients to help provide them with the best prognostic information,” said Dr. Alexander K. Smith, another of the study authors. “But somehow, we have lost sight of that responsibility as a profession.”


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