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4 - Discussing Prognosis

A Tightrope Walk between Hope and Reality

Published online by Cambridge University Press:  05 April 2024

Robert M. Arnold
The University of Pittsburgh School of Medicine, Pittsburgh
Anthony L. Back
University of Washington Medical Center
Elise C. Carey
Mayo Clinic, Minnesota
James A. Tulsky
Dana-Farber Cancer Institute, Boston
Gordon J. Wood
Northwestern Memorial Hospital, Chicago
Holly B. Yang
Scripps Health, San Diego, California
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Clinicians and patients have varying degrees of comfort in discussing prognosis. Patients can swing between worry or understanding that death is near and hope or optimism that lets them live life. This prognostication awareness pendulum may require a clinician negotiate the discussion over time. The cognitive roadmap for prognosis discussion is ADAPT (Ask what they know about their medical condition, Discover what they want to know about prognosis, Anticipate ambivalence, Provide information about what to expect, and Track emotion and respond with empathy). Some patients want prognostic information, some don’t, and some are ambivalent. While respecting their wishes, exploring why in each of these scenarios may be helpful to understand their concerns and how best to address them. Be aware that patients and their family members may have different prognostic information needs. Having separate conversations (with permission) may be in order. When they are concerned about destroying hope or prognosis is uncertain, using the frame of “hope and worry” can be helpful. Finally, when patients or family members don’t believe our prognosis, be curious as to why and focus on the relationship.

Navigating Communication with Seriously Ill Patients
Balancing Honesty with Empathy and Hope
, pp. 52 - 75
Publisher: Cambridge University Press
Print publication year: 2024

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Further Reading

Back, A. L., and Arnold, R. M., Discussing prognosis: “How much do you want to know?” Talking to patients who are prepared for explicit information. Clin Oncol, 2006, 24(25): 4209–13.Google ScholarPubMed
Campbell, T. C., Carey, E. C., Jackson, V. A., et al., Discussing prognosis: Balancing hope and realism. Cancer J, 2010, 16(5): 461–6. doi: 10.1097/PPO.0b013e3181f30e07. Review. Erratum in: Cancer J, 2011 Jan–Feb; 17(1):68. PubMed PMID: 20890141.CrossRefGoogle ScholarPubMed
Christakis, N. A., Death Foretold: Prophecy and Prognosis in Medical Care. Chicago, University of Chicago Press, 1999.Google Scholar
Jacobsen, J., deLima, T. J., and Jackson, V. A., Misunderstandings about prognosis: An approach for palliative consultants when the patient does not seem to understand what was said. J Pall Med, 2013, 16(1): 91–5.CrossRefGoogle Scholar
Jenkins, V., Fallowfield, L., and Saul, J.. Information needs of patients with cancer: results from a large study in UK cancer centres. Br J Cancer, 2001, 84(1): 4851.CrossRefGoogle ScholarPubMed
Lakin, J. R. and Jacobsen, J., Less is more: Softening our approach to prognosis. JAMA Intern Med, 2019, 179(1): 56.CrossRefGoogle Scholar
Rodin, G., Lo, C., Rydall, A., Shnall, J., Malfitano, C., Chiu, A., et al., Managing cancer and living meaningfully (CALM): A randomized controlled trial of a psychological intervention for patients with advanced cancer. J Clin Oncol, 2018, 36(23): 2422–32.CrossRefGoogle Scholar
Rosenberg, A., Arnold, R. M., and Schenker, Y., Holding hope for patients with serious illness. JAMA 2021, 326(13): 1259–60.CrossRefGoogle ScholarPubMed
Temel, J. S., Shaw, A. T., and Greer, J. A., Challenge of prognostic uncertainty in the modern era of cancer therapeutics. J Clin Oncol, 2016, 34(30): 3605–8.CrossRefGoogle ScholarPubMed

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