Study of terminal patients underscores difficulties
A newly published analysis of data from SUPPORT (Study to Understand Programs and Preferences for Outcomes and Risks of Treatment) and another large-scale prognosis study document the difficulties faced by health professionals in trying to accurately predict seriously ill patients’ likelihood for survival. Neither attending physicians’ knowledge nor computerized statistical models were able to accurately predict a seriously ill patient’s likelihood of surviving the next two months, even for patients who died within a week. These results were published in a special ethics issue of New Horizons, a journal of the Society of Critical Care Medicine.
"The fact that deaths were not nearly as predictable as most would think should radically change our comfortable assumptions that we know who is terminally ill, and that we could provide different care or advise them with high confidence," explains Joanne Lynn, MD, the study’s lead author, co-principal investigator of SUPPORT and director of the Center to Improve Care of the Dying at George Washington University in Washington, DC.
"Most Americans indeed most physicians think that doctors can tell who is dying, at least in their last weeks," Lynn observes. "We used the very best of current prognostication methods, and yet it was far from clear when these gravely ill patients’ deaths were near. Most had odds of survival that supported hopefulness, and perhaps continued treatment, right up to the end." Even a week before their deaths, over half of the patients who died in SUPPORT would have been expected to survive two months.
These findings should add fuel to two burning controversies now facing hospices the audits of long-stay hospice patients by the federal Office of Inspector General (OIG) and plummeting lengths of stay for hospice patients. (See Hospice Management Advisor, March 1997, pp. 25-28.) Because of what her research has shown about prognosticating for terminally ill patients, the OIG audits are likely to curtail the availability of hospice care, particularly for patients with diseases other than cancer, Lynn says. "That can’t be what Congress intended."
Any criteria for defining the terminally ill for purposes of eligibility for health benefits or for assisted suicide, she concludes, will be "unavoidably arbitrary." (See related story, p. 42.)
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