Discussing prognosis in palliative care
At the time of diagnosis of a life-limiting illness, or when it becomes clear a patient’s condition is incurable, the patient (and family) often want an estimate of the time they have left. Most patients and their families want specific, honest information about prognosis, delivered with compassion, to help them make decisions and plan for their remaining time.
If a patient does not wish to discuss prognostic information, respect their preference but offer to discuss the subject, and explain how it may be helpful for planning and decision-making. The choice not to discuss prognosis may be associated with a patient or family’s cultural preferences. For example, some groups may prefer not to discuss prognostic information at all, or may want the family to receive it, but not the patient.
If a patient or family asks about prognosis, explore their reason for wanting to know. For example, if a friend or relative needs to decide whether to travel to see the patient, it can be helpful to know how important it is for that person to see the patient while they can still communicate.
Even when a patient wants information about their prognosis, receiving it can be very upsetting; it is important to acknowledge the patient and family’s emotions, and to show empathy.
A follow-up appointment to discuss treatment options and advance care planning may be appropriate.
For further guidance, see Guidance for discussing prognosis in palliative care. See also general guidance on breaking bad news in Guidance for breaking bad news. Australian clinical practice guidelines for communicating prognosis and end-of-life issues are available1.
Aspect of discussion | Action | Example questions and discussion points |
|---|---|---|
|
degree of detail |
Try to get a sense of how much and what type of information the patient wants. |
Some people like to know all the details about their illness and what might happen in the future, while others prefer not to know too many details. How much information would you like? For some people, prognosis is about numbers or statistics; others prefer to focus on a particular date or an event they’re looking forward to. What kind of information would be most helpful for you? |
|
expectations |
Before providing information, ask what the patient already knows and their expectations about prognosis to help frame the discussion. |
Can you tell me what the doctors and nurses have explained to you about your illness and how it might affect your health in the future? |
|
readiness |
Assess willingness and readiness to talk about prognosis; if possible, avoid these discussions when the patient is acutely ill or distressed. |
Some people like to talk about time, so that we can make plans for your care in the future. Can you explain how you feel about discussing this? |
|
uncertainty |
Acknowledge the uncertainty and limitations of prognostication. Express life expectancy as a range (eg hours to days, days to weeks, weeks to months) or in terms of milestones (eg Christmas, birthdays), or talk about ‘worst case–best case’ scenarios. |
Many people expect doctors to know what’s going to happen, but we often need to make educated guesses. Every person is different. I can only tell you what usually happens to most people in your situation. I won’t give you a specific period of time because I’ll probably be wrong, but I’ll give you a general idea of what I think is likely. In your case, I think you probably have [hours to days / days to weeks / weeks to months / months to years] to live, but keep in mind that people may die more quickly or may live longer than I think they will. |
|
When end of life is near, patients or carers often ask how much longer this situation will go on. |
Sometimes when people are close to the end, they feel this will never end. To reassure you, your time seems to be close. |