Paddy Stone, Professor of Palliative Medicine, Division of Population Health Sciences and Education, St George’s University of London, UK, explains the background to his longer article that is published in this month’s European Journal of Palliative Care.
Having to deal with questions about prognosis is very common in palliative care practice. Admittedly not many patients directly ask the question, “How long have I got left?”
Nonetheless, many of the conversations that we have with patients revolve around issues of preparation for impending death. Frequently the answers to these questions depend on our intuition about how long we expect patients to survive. Should one patient go to the hospice for terminal care? Should another be discharged from hospital as quickly as possible so that she can achieve her wish to die at home? Should this man’s relatives be summoned to the hospital to sit at his bedside? Should this lady postpone her holiday because her mother is expected to die within the next few weeks?
Unfortunately doctors’ (and nurses’) predictions about survival are inaccurate and are generally over-optimistic. Any tool that could help improve our prognostic abilities would be a valuable aid to clinical practice. My interest in prognostication was initially sparked by a research study that purported to show that the serum vitamin B12 and C-Reactive Protein index (BCI) could predict survival in geriatric palliative care patients (1). In a multi-centre study involving colleagues across several units in south-west London, we broadly replicated the results of the original report (2). However, the accuracy of the BCI was not sufficiently precise to be of enormous clinical utility and so we decided to conduct a larger prospective study to develop a novel prognostic indicator for use in palliative care populations. One of our key aims was to develop an instrument that was more accurate than a doctor’s prediction. The Prognosis in Palliative Care Scores (PiPS) were developed in a population of approximately 1,000 patients recruited at 18 sites across England over a three-year period (3). PiPS scores represent a small but significant improvement on subjective clinician estimates of survival but need further validation before they can be recommended for widespread use.
Over the past ten years an increasing number of prognostic tools have been developed. Indeed, there is now little excuse for simply relying on clinician estimates of survival. However, there is no consensus about which of the existing tools is most accurate or most clinically useful. In the recent issue of the European Journal of Palliative Care , Dr Sam Lund and I have reviewed some of the leading candidates among the new prognostic scores. Each of the scores has its strengths and limitations, but no score can currently claim to be the uncontested preferred instrument. We conclude that further research is now required to refine, evaluate and compare the existing prognostic tools – rather than to develop new instruments.
- Geissbuhler P, Mermillod B, and Rapin CH, Elevated serum vitamin B12 levels associated with CRP as a predictive factor of mortality in palliative care cancer patients: a prospective study over five years. Journal of Pain & Symptom Management, 2000. 20(2): p. 93-103.
- Kelly L, White S, and Stone PC, The B12/CRP index as a simple prognostic indicator in patients with advanced cancer: a confirmatory study. Annals of Oncology, 2007. 18(8): p. 1395-9.
- Gwilliam B, Keeley V, Todd C, Gittins M, Roberts C, Kelly L, Barclay S, and Stone PC, Development of prognosis in palliative care study (PiPS) predictor models to improve prognostication in advanced cancer: prospective cohort study. BMJ, 2011. 343: p. d4920.
Find out more…
The article to which this post relates, ‘Predicting survival in patients with advanced cancer’ by S Lund and P Stone, is published in the March/April 2013 issue of the European Journal of Palliative Care, Vol. 20 number 2.
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