Is it acceptable to label a patient as having a poor prognosis when they are not doing well?

Prognostic Labeling in Clinical Practice

Yes, it is not only acceptable but clinically necessary to label a patient as having a poor prognosis when objective clinical indicators support this assessment, as risk stratification is crucial for guiding optimal treatment decisions and ensuring appropriate care planning. 1

Evidence-Based Framework for Prognostic Classification

When Poor Prognosis Labeling is Appropriate

The American College of Rheumatology explicitly states that risk stratification is crucial for guiding optimal treatment, and the presence of even one established poor prognostic feature is sufficient to classify a patient as having poor prognosis for treatment decision-making purposes. 1 This approach is not arbitrary labeling—it is evidence-based classification that directly impacts therapeutic choices and outcomes.

The European Society of Cardiology reinforces this by emphasizing that treatment decisions should be based on parameters that reflect symptoms, exercise capacity, and variables with established prognostic importance. 1 Importantly, they note that no single parameter should be used in isolation; rather, a panel of clinical, biochemical, and imaging data should inform prognostic assessment. 1

Critical Requirements for Accurate Prognostic Assessment

Multiple prognostic indicators must be considered rather than relying on a single factor. 2 The European Society of Cardiology explicitly warns that it is crucial not to rely on just a single parameter, as several assessments may provide divergent results. 1

Key elements that should inform prognostic classification include:

• Disease-specific clinical features: Rate of symptom progression, functional status (WHO functional class), and presence of complications such as right ventricular failure or syncope 1
• Objective measurements: Exercise capacity (6-minute walk distance), cardiopulmonary testing results, and performance status scores 1, 2
• Biomarkers: Elevated and rising BNP/NT-proBNP levels, troponin, or other disease-specific markers 1, 2
• Imaging findings: Pericardial effusion, reduced TAPSE, or other structural abnormalities 1
• Hemodynamic parameters: Cardiac index, right atrial pressure, and other invasive measurements 1

The Distinction Between Prognosis and Treatment Response

A critical pitfall is conflating poor prognosis with futility of treatment. The fact that survival is poor does not necessarily imply that additional therapy is not worthwhile—what is truly needed is data demonstrating that treatment actually improves survival. 1 Conversely, poor prognosis should not automatically rule out aggressive treatment approaches in selected patients. 1

For example, in kidney cancer, the National Comprehensive Cancer Network specifically defines poor-prognosis patients as those with predictors of short survival, which then guides specific treatment recommendations including temsirolimus as category 1 evidence for this subgroup. 1 This demonstrates how prognostic labeling directly enables evidence-based treatment selection.

Communication and Documentation Standards

Prognostic classification should be based on objective, validated criteria specific to each disease state, not subjective impressions. 1 The American College of Rheumatology notes that while disease activity levels contain subjective elements, they must be grounded in published literature and clinical trial data. 1

When documenting poor prognosis, physicians should:

• Specify which objective prognostic factors are present (e.g., "poor prognosis based on WHO functional class IV, 6-minute walk distance <300m, and elevated BNP") 1
• Avoid vague terminology without supporting clinical data 2
• Include complete progress notes with clinical findings, laboratory results with reference ranges, and imaging reports with interpretations 2
• Document disease-specific risk stratification scores where available 2

Common Pitfalls to Avoid

Physicians frequently overestimate or underestimate survival time, which can be distressing to patients and families. 3 Research shows physicians display discrepancies in prognostication, with trends toward pessimism especially among early trainees and acute care specialties. 4

Additional pitfalls include:

• Using single parameters (such as pulmonary artery pressure alone) that correlate poorly with outcomes 1
• Failing to account for geographic variation and treatment differences in prognostic data 1
• Assuming homogeneous tumor biology within stage groupings when clinical characteristics may differ markedly 1
• Delaying prognostic discussions until acute crises rather than when reduced reserve is first identified 5

The Role of Prognosis in Modern Clinical Practice

A prognostic model provides a framework for clinical practice that extends beyond disease diagnosis and incorporates a wide range of information to predict future patient outcomes and guide decisions to improve them. 6 This approach integrates biological, social, and clinical data for more effective care. 6

Prognostic classification enables:

• Appropriate treatment intensification for poor-prognosis patients who may benefit from more aggressive therapy 1
• Timely palliative care referral when indicated 1, 5
• Informed consent for medical decision-making, as prognosis is an essential component patients prioritize 7, 4
• Resource allocation and care planning aligned with likely outcomes 5

Accurate prognostic awareness is associated with favorable medical outcomes at end-of-life for patients and better psychosocial outcomes for caregivers. 7 The majority of caregivers (72%) feel prognostic information is extremely or very important to possess. 7