Estimates of Patient Life-expectancy: Addressing Unrealistically Optimistic Estimates
There is plenty of evidence that we physicians, as a group, tend to paint unrealistically optimistic estimates of our patients’ life expectancy, for a number of reasons. In January 2012, JAMA published a review article titled “Prognostic Indices for Older Adults” that addresses this tendency and helps healthcare providers determine and stratify mortality risk. Lindsey Yourman, MD, the lead author of this important piece, is currently in her PGY1 year at Scripps Mercy Internal Medicine Residency Program. Yes, Dr. Yourman and her colleagues did this work while she was still in medical school! The paper is linked to a nifty interactive website called ePrognosis.org, and is a valuable tool for clinicians trying to determine realistic expectations for our patients and their families. And Dr. Yourman has kindly agreed to take time out from her busy intern year (albeit not as busy as most of us recall) to present on her work and demonstrate the ePrognosis tool at SDCMS’ Bioethics Commission meeting on July 25 from 6 p.m. to 8 p.m.
Dr. Yourman has always had an interest in geriatric medicine and plans to make this her career path. During her clinical years in medical school at UCSF, Lindsey observed firsthand how difficult it was to determine patients’ life expectancies, and also observed the suffering that sometimes resulted from decisions made on the basis of poor prognostication — and inadequate understanding on the part of patients and clinicians alike as far as expectations for survival and recovery. Dr. Yourman believed that people often opted for invasive and aggressive attempts at life prolongation based on inaccurate or overly optimistic prognostication on the part of their physicians. She searched the literature and found that there was a dearth of readily available tools to help determine prognosis in the geriatric population at large, although, with laborious research, certain patient scenarios (like some cancer patients) could yield reasonable estimates of mortality.
Dr. Yourman decided that she wanted to make a difference and approached some of her mentors, including Drs. Alex Smith and Eric Widera, about working on a user-friendly, interactive system that healthcare professionals could access to assist them in informing their patients and families about what to expect. She took an academic year off to work on this project, consolidating multiple studies of hospitalized, skilled nursing facility, and community-dwelling elders into an interactive, Internet-based tool with dropdown menus that can be individualized to specific patients and provide a range of expected mortality over various timeframes — and that is how ePrognosis came into existence.
In addition to the JAMA article from January 2012, that same month Dr. Yourman was published in the Journal of the American Geriatrics Society (JAGS); this ethnogeriatrics piece — titled “Quality of Life in Late-Life Disability: ‘I Don't Feel Bitter Because I Am in a Wheelchair’” — was derived in part from her work as project manager for interviewing older adults on their feelings about prognosis. This work has also given Lindsey a rich perspective on the attitudes of frail elders on their final phase of life.
At the July 25 Bioethics Commission meeting, Dr. Yourman will provide a real-time demonstration of the use of ePrognosis by presenting a case study; then she will discuss ethical issues surrounding discussion of prognosis, including autonomy and nonmaleficence, with attendees. Topics of advance care planning, including advance healthcare directives and POLST (Physicians’ Orders for Life Sustaining Treatment) in the context of realistic expectations and a reasonable estimate of prognosis, will be part of the relevant discussion. The Bioethics Commission of SDCMS, chaired by Mits Tomita, MD, and Paula Goodman-Crews, meets quarterly at SDCMS, and visitors are welcome. Please plan to join what will prove to be a lively discussion on July 25 from 6 p.m. to 8 p.m. Please RSVP to Kyle Lewis at KLewis@SDCMS.org if you would like to attend.