When discussing prognosis, physicians face a series of contradictory impulses. For many, telling patients that their illness will take their life makes doctors feel like they are giving out a “death sentence.” The prognosis conversation is difficult, and often times it's easier to let these issues slip into the background and focus instead on symptoms, logistics, or hoping the patient will respond to treatment. Yet, these same physicians also know that when patients don't realize how close to death they really are, they often fail to make plans, including sharing preferences for the medical care they want at the end of life. When this occurs, families and clinicians are left making decisions for them - often with conflict and heartache. Thus, for many physicians, the impulse to inform the patient and the impulse to avoid a discouraging discussion coexist.

Patients have their own contradictory impulses. On one hand, in surveys, patients consistently say that they want a great deal of prognostic information. For example, in one British study, 87% of patients wanted “all possible information.” On the other hand, patients also warn clinicians about being “too blunt,” and say that “supporting hope” is very important. To further complicate matters, a significant minority of patients wants to avoid prognostic information altogether, and in some cultures, to speak about a bad prognosis creates a self-fulfilling prophecy. How can a doctor possibly get this right?