Prognostication: Principles and Practice

Prognostication

Principles and Practice

Bernardo Gutierrez

Copyright © 2024 Bernardo Gutierrez, MD

All rights reserved

First Edition

PAGE PUBLISHING

Conneaut Lake, PA

First originally published by Page Publishing 2024

ISBN 979-8-88960-938-4 (pbk)

ISBN 979-8-88960-960-5 (digital)

Printed in the United States of America

Table of Contents

I dedicate this book to my wife for her unconditional love and support throughout my long career, never faltering and always believing in me. Also, to my children who have supported and helped me in the last steps of the process.

Chapter 1

Overview of Prognostication

Chapter 2

Maximum Potential Life Span

Chapter 3

Factors and Markers of a Reduced Potential Life Span

Chapter 4

Methods Used to Determine Life Expectancy

Chapter 5

Process

Chapter 6

Prognosticating

About the Author

I dedicate this book to my wife for her unconditional love and support throughout my long career, never faltering and always believing in me. Also, to my children who have supported and helped me in the last steps of the process.

Chapter 1

Overview of Prognostication

The practice of medicine has become scientifically complex. While aggressive and potentially lifesaving therapies have emerged for even the deadliest of diseases, physicians need to recognize that many of these advanced treatments are not appropriate for all patients. This is particularly true for the elderly. Many elderly patients do not have the physical reserves that they would need to recover functionality and thus may not be able to tolerate even the temporary negative effects of aggressive care. To combat this problem, physicians need to gain expertise in the art and process of prognostication, which is a method or process that can be used to predict future outcomes based on a critical evaluation of current knowledge. The process of prognostication needs not be complex or time-consuming. At its core, prognostication uses standard clinical observations to help physicians predict the relative benefits of aggressive and potentially curative versus supportive and typically more palliative care for each patient case. In this chapter, we review the basic issues involved in identifying appropriate medical care for elderly patients and provide a general overview of how prognostication can assist in this process in routine clinical practice.

Objectives

The goals of this section are as follows:

To understand the problem

To recognize the importance of prognostication with respect to the practice of medicine in a changing population

To provide a general overview of the theory and practice of prognostication

To appreciate the physician's perspective on prognostication

To identify the advantages of prognostication in the practice of medicine

Introduction

The practice of medicine is currently in the midst of crisis in the United States (US). While our country expends the highest percentage of the gross national product on health care of any nation in the developed world, the US scores among the lowest on metrics that evaluate the quality of health care provided to its residents. The health care system is not providing people with what they need. Many complex factors contribute to this problem.

Perhaps first and foremost, medicine in the US evolved based on a purely scientific model. This approach undoubtedly led to many significant advances in medical science. The US is certainly one of the countries with superior medical knowledge. At current writing, there are medical specialists that focus on almost every type of condition or disease. With this increase in knowledge, the expectations of the general public have also increased, and the common understanding is that specific diseases need to be treated by dedicated specialists.

While this specialized approach has worked and continues to work well for patients with single medical issues, it tends to complicate the care of those with complex multisystem conditions. This is particularly evident in the care of hospitalized patients who are typically referred to different physicians for their numerous problems. In these cases, the oversight provided by the primary care physician frequently becomes diluted, and the patients lose critical continuity of care. Currently specialist-based care typically focuses on a single disease process and uses established protocols with little to no consideration of whether a given treatment is appropriate for a particular patient. Patients with more than one disease or disorder are frequently asked to see many physicians, often a single specialist for each medical issue. In these cases, no one claims sole responsibility for the patient's medical care. While this approach has worked reasonably well for patients with single issues, it certainly does not address the medical concerns of the overall population.

The characteristics of the patient population in the US are currently changing.¹ Not only is the population increasing in size, but the inhabitants are also generally older, weaker, and more dependent on medical care; these individuals frequently present with many highly complex medical issues. Thus far, no evidence-based standards of care have been developed to manage patients with multisystem disorders.² Furthermore, variabilities associated with different rates of aging are significant enough to require reconsideration of many of the current methods used for medical standardization. Enforcing these outdated standards will create unwanted, unnecessarily expensive, and futile medical care. It is also critical to recognize that we are just at the beginning of this period of massive change. The most significant changes in population dynamics have just begun, and they are predicted to continue for the next several decades.

Many individuals in our society have developed unrealistic expectations of modern medicine and believe that physicians can cure all diseases and thus prolong life. Many individuals perceive death as a punishable failure on the part of the physician. The liability concerns that have developed based on this unreasonable perception together with the commercialization of medicine, the introduction of the concept of productivity in medical practice, and the current economic crisis have all challenged the practice of medicine and have placed physicians at a critical crossroads.

As a final point, it is also important to understand that the current system profits by keeping the patient sick and in need of more (and more expensive) care. This system is unlikely to change, especially because many of the stakeholders (notably those in the medical insurance industry) are more or less happy with the way things are right now.

All these factors working together have created a health care system based on profit-making, rather than on the medical needs of the patients.

This system needs to change soon. The challenge to evoking change is, by its nature, complex, and in this case, there is no simple or straightforward solution. However, one thing that physicians can do in the meantime is to change the way they approach the care of the individual patient. In a large sense, the practice of medicine needs to go back to basics. Physicians need to begin by evaluating their complex patients individually and personalizing their care based on their unique situations.³ In short, physicians need to make the best out of each encounter with every patient in their practice.

Of course, not all changes are bad. Computer-based systematization of patient information has been good overall for the practice of medicine. Today physicians in almost every setting will have access to all the pertinent information needed