Abstract
The forecasting and foretelling of prognosis is a central feature of palliative care. Nicholas Christakis galvanized our field when he showed that highly experienced physicians, including those working in hospice programs, are systematically overoptimistic in their formulated prognoses for their patients by a factor of 5–in other words, 500% more optimistic than reality. 1 Subsequent work showed that the better the physician knows the patient (including hospice doctors), the more optimistic the physician is; the best prognosticator is the one who has never seen the patient before. 2 Christaskis's book is a tour de force on the history, philosophy, and science of formulating and foretelling prognosis. 3 If we are committed to patient-centered care, we must begin with the fundamental questions that patients have: What is wrong with me? (diagnosis); What will happen to me? (prognosis); and What can you do for me? (treatment).
The field of palliative medicine has pushed to get the balance right between these three fundamentals of health care. Journal of Palliative Medicine has published a host of articles over the years in an effort to improve the accuracy of prognosis. Performance status is still the central prognostic factor. The brilliantly simple Zubrod/WHO/ECOG performance scale hinges on the answer to a single question: How much of your waking hours must you spend lying down in bed? The Palliative Performance Scale built on those observations of performance status and achieved modest improvements in accuracy. 4
A refined tool with the Palliative Performance Status scale at its core appears to improve the prediction of survival less than seven days. 5 In this report the comparison was nurses working in a hospice program. Interestingly, nurses are also systematically overoptimistic; the tool helped correct for their overoptimism. In the program where I work we admit patients with a prognosis of less than seven days to a specialized team in order to be sure to get the patients and families what they need, and to avoid spending time, money, and effort on the things they don't need. In a similar manner, our Canadian colleagues want to be sure that only patients with short prognosis are admitted to scarce palliative care beds. 6 In both examples it's about getting the right care to the right patient at the right time.
We have to get the prognosis right if we're going to get the treatment right. Controlled sedation for refractory suffering, frequently referred to as palliative sedation, is one treatment for patients who are close to death and experience suffering (physical, emotional, practical, or spiritual) refractory to maximal efforts of interdisciplinary palliative care. 7 While the focus of the report from Germany is on the number of people being treated with palliative sedation, it highlights the role that electronic data collection from all patients is playing, and will play, in assessing whether the treatment was applied at the right time and in the right way. Judgments about the right time and the right treatment are based on ethical frameworks. Andy Billings, a palliative medicine pioneer in the United States, reviews frameworks other than the Principle (Doctrine) of Double Effect developed by the philosopher and theologian Thomas Aquinas (1225–1274). 8 He argues that we mustn't be trapped by one perspective—we must be aware of all of the perspectives as we persevere in getting the right treatment to the right patient at the right time.
It is thrilling for me as editor in chief to see the rising number of submissions to Journal of Palliative Medicine. Our rising impact factor, along with the rising impact factors of our sister journals in the field, is evidence that our field is not just being noticed, but essential to the further development of health care. It's terrific to see research that is designed to answer the gritty questions that confront us daily in practice, and help us all to get the right treatment to the right patient at the right time.