Prognosticating

One of the most difficult tasks in medicine is predicting how long someone with a terminal illness will live. People enjoy repeating stories of patients who survived long after the date their doctor predicted. In most cases, however, physicians tend to be overly optimistic, and short estimates are more accurate than longer ones (Evans and McCarthy, 1985).

Physicians overestimate survival more than 60% of the time and underestimate it only 17% of the time (Christakis and Lamont, 2000). In addition to physicians overestimating prognosis, many patients believe their treatment at the end of their life (e.g., radiation) is intended to be curative, when in reality it is palliative. The better that physicians know their patients, the more they overestimate survival, probably hoping the best for patients they know well. The longer the physician has been in practice, the more accurate the prognosis. Most patients want optimistic physicians, but at some point, this optimism may delay palliative treatment.

Attempts have been made to develop indexes (e.g., Kar-nofsky score) to assist the physician in making objective estimates that correlate with actual survival. However, no accurate method is currently available, largely because of the multiple variables that influence when a patient dies. A good policy is to provide a conservative estimate. It is better to have the patient and family proud that they "beat the odds" or exceeded the physician's prediction than to have the patient die earlier than anticipated.

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