The question in the title is one that patients commonly express these days. This certainly is a change in outlook compared with attitudes present when I was a resident more than 40 years ago. At that distant time, patients and family were often fearful of asking this question because they expected the stereotypical response, “You have only 6 months to live.” Of course, this statement usually turned out to be false. None of us can predict the future. Indeed, as the Danish artist, cartoonist, and humorist Storm Petersen (1882-1949) used to say: “It is hard to predict, especially about the future.”
Today, patients and families are far better informed compared with 40 years ago as a result of media and the Internet orientation. Consequently, patients frequently ask about their prognosis or the prognosis of loved ones. Some individuals have even learned the term “prognosis” from their Internet study. So, how do I answer this question without giving each patient a mini-course in biostatistics? What I usually do is to relate an analogous situation from the world of gambling or sports. My comments run something like this: Of course, I cannot tell the future. I do know that one day, every one of us is going to die. The 2 questions we would like to know are at what age will we die and how painful will it be? Personally, and I am sure this is true for you as well, I would like to die peacefully and without pain at a very advanced age when I am tired of life. I then go on to tell them the following sports gambling analogy. If I could foretell the future, we would not be sitting here talking. Rather, we would be at the horse track, making bets and getting very, very rich. Or, we could go to Las Vegas and come home with suitcases full of money. Unfortunately, we can’t do that. All we can do is make educated guesses about the future, and that is what is involved when doctors talk about prognosis or in simpler terms the long-term outlook. Let’s talk for a minute about horse racing. You know that every individual horse has odds associated with that animal. These odds are based on how well that horse has competed in the past along with some other factors, such as the experience of the jockey, the weather conditions, and so forth. The horse with the best odds usually wins, but rarely, the horse that is given 100 to 1 odds against winning actually does win the race.
At this point, what I say depends on whether I am in the outpatient department with a patient who is doing well or with a critically ill patient in the coronary care unit. To the stable outpatients who have few if any risk factors for premature death, I am encouraging. I tell these patients that they are the favored horse. I also emphasize again that I cannot predict the future, but that from my vantage point it looks good for them and expect that they will live for many more years.
In the case of critically ill inpatients, it is usually the family who asks about prognosis. The patient is usually too sick to pose insightful questions. What I say in this case is that it is hard to predict with any accuracy, but the odds are not terribly good in that the patient is very ill. Sometimes, I might even say, “Chances are 50/50 that your relative/loved one will survive this heart attack.” However, I always add that our team is going to do everything possible to make the favorable outcome happen.
Finally, there are the patients who clearly are not going to survive, usually individuals with cardiogenic shock or progressive renal failure, requiring high-dose intravenous vasopressors. In these cases, I am forthright with the family and the patient if they ask, telling them that the outlook is indeed poor but that there is always a small chance that things will turn around and the patient will get better. In addition, I always say the following: “We don’t keep any secrets here. We will tell you everything that is happening and what it means. A member of our team is always in the hospital and available.”
In both the outpatient and inpatient settings, patients usually thank me for being honest and frank with them. And when the news is good, they are grateful to have had their anxiety eased.
This article was originally published on our website.
– Joseph S. Alpert, MD
This article originally appeared in the January 2014 issue of The American Journal of Medicine.
