HM15 Session Analysis: End-of-Life Discussions


HM15 Session: Facilitating End-of-Life Discussions: Prognosis in Advanced Illness

Presenter: Julia Ragland, MD, FHM

Summation: Discussion of Prognosis in Advance Illness is a key component of informed decision-making and should be undertaken during a “Sentinel Hospitalization” and at times of other “triggers”. End-of-Life discussions are critical for providing the best care for patients with advanced diseases.

A Sentinel Hospitalization is a hospitalization in the patient’s disease course that heralds a need to reassess prognosis, patient understanding, treatment options and intensities, and goals of care.

Other triggers for discussing prognosis: new diagnosis of serious illness, major medical decision with uncertain outcome, frequent hospitalizations for advanced disease, patient/family query prognosis, patient/family request treatment inconsistent with good clinical judgment (futile care), patient actively dying, “No” answer to “Surprise Question” (“would you be surprised if this patient died in the next year?”)

How can we prognosticate? Data from studies, Clinical intuition and experience, Prognostic indices, Key indicators of worsening prognosis (declining functional status, weight loss/malnutrition, co-morbidities, frequent hospitalizations)

Resources for Prognostication: ePrognosis, Seattle Heart Failure Model, MELD, Charlson Comorbidity Index, MJHSpalliativeinstitute.org/e-learning, Palliative Care Fast Facts mobile app

Ask-Tell-Ask method for communicating prognosis

  • ASK: if they want to talk about prognosis and what they already know
  • TELL: give information in small amounts, build on what they already know, use simple straight-forward language
  • ASK: repeat understanding of what has been said, if they would like to hear more

Key Points/HM Takeaways:

  • Estimating and discussing prognosis are core competencies for hospitalists and should be utilized during a “sentinel hospitalization”
  • Prognostic awareness in advanced illness is key for:
    • Informed decision making (CPR, procedures, chemo, et al)
    • Determining realistic goals of care
    • Providing patient centered care
  • Most patients and families want prognostic information, but not always- must ask to know. Give the patient the option not to discuss prognosis.
  • Ask-Tell-Ask approach for discussing prognosis is effective

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