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  Written by
  Nicholas A. Christakis

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The prophetic art

 



A University of Chicago physician explains how hard--
and increasingly, how necessary--it is for doctors to tell patients
what the future may hold.

image: FeaturesOn numerous occasions, patients have asked me if they would be cured of their cancer, if their pain would ever stop, if they would live until the end of the week, or until their next Christmas, their next anniversary, their next child's graduation from high school. These questions pained me, and not just because they touched on the ineffable sadness of deadly disease or the efforts the dying often make to stay connected to the living. They pained me as well because it was so difficult, yet at the same time so essential, to answer them.

Trained both as a physician and a sociologist, Nicholas A. Christakis has a joint appointment in the departments of medicine and sociology at the University of Chicago; his clinical practice consists of caring for terminally ill patients at home. This article is adapted from his new book, Death Foretold: Prophecy and Prognosis in Medical Care (University of Chicago Press, 1999).

1999 The University of Chicago

Over the course of my clinical training, I came to regard explicit, precise, and compassionate responses to patients' requests for prognosis to be a key part of my role as a physician. I came to see the deliberate assessment of prognosis as absolutely obligatory, even if patients did not happen to ask. Yet I found that I had been poorly trained for this.

Textbooks omitted prognosis, journals avoided it, and medical schools ignored it. The whole profession seemed to overlook prognosis. And few of my colleagues shared my conviction that this might be a problem. They even seemed bemused by my interest in this "marginal" topic, as if the proper and scientific role of medicine were only to diagnose and treat disease, not to predict its outcome.

Was prognosis really so unimportant? Were the obstacles to it really insurmountable? When it came to prognostication, physicians appeared to speak hesitantly, softly, and ambiguously--if at all. This contrasted markedly with the confidence they exuded when making a diagnosis or prescribing a therapy.

I ultimately concluded that the muffled presence of prognosis had a lot to do with the raging authority of death. Prognostication and death are tightly interwoven. Although there certainly are more routine, less serious incarnations of prognostication, if one asks doctors to free-associate with the word prognosis, they are apt to say "death." And when physicians are asked to think about the role of prognosis in their practice, the question they imagine--and dread--is "How long do I have to live?" Like death, prognostication seems mysterious, final, powerful, and dangerous.

On more than one occasion, I have seen the avoidance of prognostication, or needlessly incorrect prognoses, harm patients. A recent newspaper article entitled "For Cancer Patients, Hope Can Add to Pain" poignantly captured how such harm can come about. It quoted a patient's wife as saying:

The Thursday before my husband died, I thought he was dying. But the doctor was talking about aggressive chemotherapy. I asked if this was palliative, and he said that he still hoped for a cure. I was with him at the time of his death [three days later], but the room was filled with eight other people hanging bags of blood and monitoring vital signs. It was about as horrifying as anything that could have happened. I don't think the [doctors] were trying to mislead us. They thought he might be the one case that would have a positive outcome. [But if I had been told the truth,] we could have spent days with the children, together, not filled with painful regimens in the hospital.

The failure to predict this patient's death--in the sense of not thinking about the prognosis clearly, in the sense of not articulating it, and in the sense of encouraging an unduly optimistic expectation--was harmful. Such a failure can contribute to a therapeutic imperative that prevents families from taking steps to prepare for death. The physicians did not want to see that the therapy would not result in the desired outcome. They did not want to predict that the patient was about to die. And they did not want to take action, such as limiting therapy, based on such a prediction. My feeling is that the problem in this case, and countless other cases like it, arises more from errors in prognosis than from errors in therapy. In our rush not to abandon patients therapeutically at the end of life, we abandon them prognostically.

And yet, cogent and compassionate prognostication could decrease the prevalence of bad deaths in our society. Such prognostication is a sensitively delivered and well-calibrated best guess about the patient's future. It requires physicians to be as versed in the art and science of prognosis as they are in diagnosis and therapy, to make strenuous efforts both to learn the state of the art with respect to the prognostic problem presented by the patient and to communicate that knowledge in a way that the patient can comprehend, to the extent that the patient wants this. Moreover, it requires physicians to adopt a broader view of the meaning of hope and to realize that there is much patients can realistically hope for even if death is imminent and unavoidable.

Such prognostication includes physicians' willingness to spend time talking with patients, assuring them that they will not be abandoned. It entails, finally, the willingness of physicians to act on predictions, despite the risk of error. Such behavior by physicians would reflect the realization that temporizing or self-delusion in prognosis can be as harmful to patients as an incorrect diagnosis or a mistaken treatment. And such behavior would, ultimately, reflect the very real moral aspects of prognostication.

These are not easy things to do, of course, and there is good reason that physicians avoid prognostication, beyond the fact that it is technically difficult and emotionally frightening. Prognostication can hurt patients, and not just when it is inaccurate. Some patients do not wish to be provided with prognostic information. And I am deeply empathetic to the complexity of prognostication. What I am suggesting is an approach that balances the benefits of prognostication against the benefits of avoiding it, an approach that realizes that unfavorable predictions do not mean physicians have nothing to do and patients nothing to hope for, an approach that recognizes that acting on an uncertain prediction may be better than making no prediction at all.

A better understanding of how physicians prognosticate is justified not only by the prospect of enhancing patient care, but also by contemporary developments that are increasing the importance of predictions.

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