What care approach is taken when a patient has a poor prognosis?

Care Approach for Patients with Poor Prognosis

When a patient has a poor prognosis, the care approach should focus on palliative care with the aim of optimally alleviating symptoms through medication and non-medication measures, while incorporating discussions about death and preferred place of dying as part of medical consultation. 1

Core Principles of Care for Poor Prognosis Patients

Communication and Decision-Making

• Open communication with patients (when possible) and relatives is a precondition for comprehensive support when prognosis is poor 1
• Discussions about death and preferred place of dying should be incorporated into medical consultation rather than avoided 1
• Most older adults wish to discuss prognosis, and clinicians should use a culturally sensitive manner as culture often influences priorities 1
• Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (remaining life expectancy, functional status, quality of life) 1

Integration of Palliative Care

• Early integration of palliative care is recommended for patients with progressive diseases and poor prognosis 1
• For patients with advanced underlying disease and poor prognosis, palliative care should focus on symptom alleviation 1
• The continued pursuit of disease-modifying therapy should be balanced and integrated with a palliative approach 1

Specific Clinical Approaches

Symptom Management

• Symptom control should be prioritized even when cure is not possible 1
• For pain management in terminal patients, opioids like morphine may be appropriate, with careful monitoring for respiratory depression, especially in elderly, cachectic, or debilitated patients 2
• When using opioids, monitor for potential drug interactions, particularly with benzodiazepines or other CNS depressants which can increase risk of respiratory depression 2

Treatment Limitations and Goals of Care

• If prognosis assessment shows no prospect of recovery, therapy limitation should be discussed with relatives 1
• In patients with advanced disease, a therapy limitation with symptom-reducing support can be offered after discussions with patients and relatives 1
• Time-limited trials of therapy may be appropriate in some cases, with regular reassessment of prognosis and therapy goals 1

Special Considerations for Different Conditions

• For patients with terminal lung disease (e.g., COPD, pulmonary fibrosis), termination of respiratory therapy under palliative care should be considered when appropriate 1
• In patients with devastating brain injury, accurate prognostication is difficult, particularly early on, and there is risk of a "self-fulfilling prophecy" with early withdrawal of life-sustaining therapies 1
• For patients with cancer and poor performance status, progression through multiple lines of therapy has low likelihood of response, while hospice care offers greater home support and better quality of life 1

Pitfalls to Avoid

• Avoid adhering to an incorrect poor prognosis which might lead to insufficient diagnostic procedures or treatment 3
• Be aware that physicians frequently over or underestimate survival time, which can be distressing to patients and families 4
• Recognize that prognostication can be highly variable among providers, with accuracy not necessarily tied to experience or subspecialty expertise 5, 6
• Avoid making decisions based solely on baseline assessments; incorporating short-term reassessments can improve prognostic accuracy 7

Algorithm for Care Approach

1. Assess prognosis using validated tools specific to the patient's condition 1
2. Engage in open communication about prognosis with patient/family 1
3. Determine patient's goals and preferences for care 1
4. Implement appropriate symptom management strategies 1, 2
5. Consider time-limited trials of therapy when appropriate 1
6. Integrate palliative care early in the disease course 1
7. Reassess regularly and adjust care plan as needed 1, 7