A patientís understanding of their illness is key when making informed treatment decisions. According to a study recently published in the The Oncologist, 60% of terminally ill cancer patients have accurate awareness of the prognosis of their condition and tend to become more aware as their condition deteriorates.1 Prognostic awareness is an important aspect of decision making at the end of life and promotes a better quality of life and preparation for death.
The researchers in this study differentiated 247 patients into four states: unknown and not wanting to know prognosis; unknown but wanting to know prognosis; inaccurate awareness of prognosis; and accurate awareness of prognosis. All patients were interviewed during the last 6 months of care.
Initially, 8.1% of patients did not know and did not want to know their prognosis, and 17.4% did not know but wanted to know the prognosis. Fifteen percent of the patients viewed the prognosis inaccurately and 59.5% of patients had accurate prognostic awareness.
Patients categorized as not knowing/not wanting to know were least likely to progress to other awareness categories. However, 82% of patients had progressed to an accurate awareness of their prognosis before death. Eighteen percent still did not have a complete understanding of the prognosis, and 3.6% of those patients were in complete denial and unable to make sufficient preparations for their death. The unwillingness to face a poor prognosis can lead to unnecessary treatment and may prevent the patient from making appropriate end-of-life plans, creating more stress during their remaining time.
Physicians should not wait to discuss prognosis with terminally ill patients until the patient or their family members bring up the issue or when curative treatment is no longer available. This study provides quantitative evidence of variations in willingness to receive information regarding prognosis, and recommends that physicians discuss the prognosis closer to the patientís diagnosis of advanced cancer so that they are cognitively competent to make informed decisions about end-of-life care.
Patient-clinician communication about prognosis does not need to take away the patientís hope, but rather offers the opportunity to improve end-of-life care, such as allowing the patient the choice to die in their preferred setting and ensuring bereavement support for their family.
After a diagnosis of incurable cancer, patients must cope with numerous stressors including the need to make treatment decisions, managing adverse effects of diagnosis and treatment, and uncertainty about the future. Health care professionals should assess the patientís readiness for prognostic information and respect their reluctance to confront the poor prognosis if they are not ready to know, but should also carefully try to coach the patient toward coming to terms with their prognosis.
1. Chen CH, Wen F-H, Hou M-M, et al. Transitions in prognostic awareness among terminally ill cancer patients in their last 6 Months of life examined by multi-state Markov modeling. Oncologist. 2017; Jul 6. doi: 10.1634/theoncologist.2017-0068. [Epub ahead of print]