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Education in Palliative and End-of-life Care - Oncology

The. EPEC-O. TM. Education in Palliative and End-of-life Care - Oncology. Project. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

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Education in Palliative and End-of-life Care - Oncology

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  1. The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

  2. EPEC - Oncology Education in Palliative and End-of-life Care - Oncology Module 8 Clarifying Diagnosis and Prognosis

  3. Objectives • Describe the difficulty with prognostication • Discuss limitations of current prognostic models • Apply the 6-step protocol to communicate diagnosis and prognosis

  4. Video

  5. Importance • Most people want to know • Strengthens physician-patient relationship • Fosters collaboration • Permits patients, families to plan, cope

  6. Inaccuracy of prognostication9

  7. Clinical predictions vs. actual survival • Over optimistic by factor of 3 - 5 Glare P.BMJ.2003.

  8. Clinical predictions vs. actual survival • Relationships between predictions and survival • Actual is 30% less than predicted • Survival = predicted  1 week for 25% • Predicted  survival + 4 weeks for 27% Glare P. BMJ.2003.

  9. Sources of prognostic information • Physician prediction • Stage-specific survival data • Performance status • Signs and symptoms • Integrated models

  10. Sources ofsurvival data . . . • Stage specific survival curves • Natural history studies • Randomized trials with a ‘best supportive care’ arm

  11. Natural history studies

  12. Performance status and prognosis . . . • Independent prognostic factor • Karnofsky Performance Score <50: survival <8 weeks Mor V, et al. Cancer. 1984.

  13. . . . Karnofsky Score as predictor of survival Reuben DB, Mor V, Hiris J. Arch Intern Med. 1988.

  14. Clinical signs and symptoms as prognostic indicators in patients with advanced disease

  15. Prognostic impact

  16. 6-step protocol . . . • Getting started • Find out what the patient knows • Find out how much the patient wants to know Adapted from Robert Buckman

  17. Communicating prognosis . . . • Some patients want to plan • Others are seeking reassurance

  18. . . . Communicating prognosis . . . • Limits of prediction • Hope for the best, plan for the worst • Better sense over time • Can’t predict surprises, get affairs in order • Reassure availability, whatever happens

  19. . . . Communicating prognosis . . . • Inquire about reasons for asking • “What are you expecting to happen?” • “How specific do you want me to be?” • “What experiences have you had with: • others with same illness?” • others who have died?”

  20. . . . 6-step protocol • Share the information • Respond to patient, family feelings • Plan, follow-up Adapted form Robert Buckman

  21. . . . Communicating prognosis • Patients vary • ‘Planners’ want more details • Those seeking reassurance want less • Avoid precise answers • Hours to days. . .months to years • Average

  22. Summary • Prognostication is inexact • Karnofsky performance status is an important prognostic factor • In advanced (<3 months) disease, symptoms predict prognosis • Prognosis is difficult to define for patients with survival >6 months

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