Definition and prevalence
Prognostication in palliative care refers to the process of predicting the likely course and outcome of a disease, particularly in estimating the time remaining for patients nearing the end of life. [1,2] This includes the use of various tools and clinical judgements to guide treatment decisions and care planning. [2,3] Palliative care needs assessment focuses on identifying the physical, emotional, social and spiritual needs of patients with life-limiting illnesses to provide holistic, patient-centred care. [4,5]
Assessment
Prognostication tools in palliative care are important for identifying patients who may benefit from palliative interventions. [1,2] The Surprise Question (SQ), which asks clinicians if they would be surprised if a patient died within a specified period of time (usually 6-12 months), is a widely used tool that helps identify patients who need further assessment and palliative care. [1,6] Despite its simplicity, the accuracy of the SQ can vary between clinicians and especially among patients with complex conditions like frailty. [6,7]
The Supportive and Palliative Care Indicators Tool (SPICT) aids healthcare professionals in identifying patients with deteriorating health due to advanced conditions and unmet supportive care needs, promoting timely and comprehensive palliative care planning. [2,8] Similarly, the Palliative Performance Scale (PPS) measures a patient’s functional status, providing a score that helps in prognostication and planning appropriate interventions. [9,10]
Another important tool, the Palliative Prognostic Index (PPI), uses clinical variables such as performance status, oral intake and symptoms like dyspnoea and delirium to predict survival, aiding in informed decision-making about the timing and intensity of palliative care. [2,11] Palliative Care Needs Rounds, involving multidisciplinary discussions about patients with complex conditions, ensure comprehensive care by addressing all aspects of a patient’s needs. [12,13]
Question Prompt Lists (QPLs) are designed to encourage patients to ask questions about their prognosis, treatment options and care preferences. [14,15] QPLs can improve communication between patients and healthcare providers, ensuring that patients' concerns and preferences are addressed during consultations. [14,15] They are particularly useful in facilitating discussions about palliative care and end-of-life planning, helping patients to make informed decisions about their care. [14,15]
Comparatively, each tool has its strengths and limitations. The SQ is quick and easy to use but may lack precision in certain populations. [1,6] SPICT and PPS provide more detailed assessments but require more time and training to implement effectively. [8,9] The PPI is particularly useful for predicting survival but may not capture all dimensions of a patient’s condition. [2,11] Needs Rounds ensure holistic care but depend on the availability of a multidisciplinary team. [12,13] QPLs enhance patient engagement and ensure their preferences are central to care planning, but they rely on patients’ willingness to participate and ask questions. [14,15]
It is important to note, other assessment tools exist and can be selected based on the clinical setting and resources available.
Treatment
Palliative approaches to care should be present from the initial diagnosis of a life limiting illness. However, the focus should shift to palliative care when the goals of care need to change from prolonging life to enhancing quality of life. [16,17] This transition often includes deprescribing unnecessary medications that may no longer provide benefit and could cause harm as a patient nears the end of life. [16,17] It involves a careful evaluation of the patient's current medications, considering factors such as life expectancy, goals of care and potential side effects. [16,17] Deprescribing can be particularly important in managing symptoms and improving the quality of life for patients with multiple chronic conditions. [17,18] For example, patients with advanced cancer or end-stage organ failure often take multiple medications, some of which may no longer be necessary or may contribute to adverse effects. [1,2] By carefully evaluating and discontinuing such medications, healthcare providers can help reduce unnecessary drug interactions and side effects, enhancing patient comfort and well-being. [1,17]
Anticipatory prescribing refers to the practice of pre-emptively providing injectable medications to manage symptoms such as pain,
nausea,
dyspnoea and anxiety in patients approaching the end of life. [19] This approach ensures that medications are readily available for timely administration, thereby preventing symptom crises and reducing emergency hospital admissions. [19] When recognising the last months of life, anticipatory prescribing allows palliative care teams to develop comprehensive and individualised care plans that anticipate potential symptom exacerbations. [19] This proactive method enhances patient comfort and supports family carers by equipping them with the necessary tools and confidence to manage distressing symptoms at home. [19] Effective implementation of anticipatory prescribing requires standardised training from healthcare professionals, and efficient management of medication supply and storage, which collectively improve the quality of end-of-life care. [19]
Incorporating discussions about prognosis and advance care planning are essential for high quality palliative care. [20,21] Clear communication about the limitations of curative treatments and the benefits of palliative care helps patients and families make informed decisions. [20,22] For example, studies have shown that timely discussions about goals of care in advanced cancer can improve patient satisfaction and align treatment with patient preferences. [2,22]
The ethical considerations in transitioning from curative to palliative care are also significant. Providers must navigate the balance between offering hope and being realistic about outcomes, ensuring that patients and families understand the shift in focus without feeling abandoned. [23,24] The literature emphasises the importance of a compassionate approach, where the patient’s values and preferences are central to care decisions. [1,24]