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Editorial: Assess a Seriously Ill Patient's "Prognostic Awareness" Before Transfer to Tertiary Center

Key findings

  • Before transferring a seriously ill patient to another hospital, consider the losses that can be associated with doing all that can be done when efforts might be better spent on ensuring comfort
  • Before transferring a seriously ill patient to another hospital, clinicians should assess the patient's and family's understanding of the prognosis in terms of likely longevity and quality of life
  • The more unpredictable the illness trajectory is, the worse the effect of delaying conversations about prognosis is
  • A palliative care physician can help ensure that patients and their families have the information they need to engage in medical decision-making

"The hope of patients and families is a precious thing," palliative care physicians Leah B. Rosenberg, MD, and Juliet C. Jacobsen, MD, affirm in an editorial in the Journal of Hospital Medicine. Reflecting on their work in the Division of Palliative Care and Geriatrics at Massachusetts General Hospital, they explain that their role is never to take away hope, but rather to reframe a patient's and family's wish for recovery into the realm of the achievable.

A Caution About Hospital Transfers

Dr. Rosenberg and Dr. Jacobsen addressed hospitalists and other generalist clinicians about hospital transfers, which can have substantial drawbacks for seriously ill patients. Compared with keeping the patient in the home hospital, these can include:

  • Increased risk of adverse events
  • Lapses in the documentation and provider communication
  • A longer length of stay
  • Higher costs
  • Higher risk of mortality

A patient can become functionally trapped in the accepting hospital—too sick to undergo meaningful disease-directed therapy and too medically unstable to return to their home community. Clinicians need to consider the losses that can be associated with "doing everything" when efforts might be better spent on ensuring comfort.

Assessing Prognostic Awareness

When talking with patients about what can be done, clinicians typically focus on medical issues and overlook the need to assess prognostic awareness, or the patient's understanding of their prognosis in terms of likely longevity and quality of life. Before transferring a seriously ill patient to another hospital, clinicians should ask questions such as:

  • What is your understanding of your health or current medical situation?
  • Can you share more about what you are hoping for with this illness?
  • Are there other hopes that you have related to this illness?
  • What are your biggest worries?
  • If no further treatments were possible at the next facility, what would then be your biggest worries?
  • What would the potential drawbacks of a transfer be from your point of view?

Delay Can Be Damaging

When patients are having difficulty coping, clinicians often delay conversations about prognosis in hopes that more time will help the patient better adapt. On the contrary, delaying such conversations actually makes it harder for patients and families to understand and prepare for what might happen. They are therefore less well equipped than they might otherwise be when asked to make medical decisions.

They found that it is especially more dangerous to delay conversations about prognostic awareness when there is a more unpredictable illness trajectory.

Palliative Care Intervention Impact

When patients have low prognostic awareness, a palliative care physician can help ensure that patients and their families have the information they need to engage in medical decision-making. The gold standard is an in-person consultation between the patient and physician, and telemedicine may be available to help. However, the palliative care physician may be able to consult with the local provider to offer expert advice.

If a nuanced assessment is impossible, access to palliative care expertise is a legitimate reason for a hospital transfer.

Learn more about the Divison of Palliative Care and Geriatric Medicine

Refer a patient to the Division of Palliative Care and Geriatric Medicine

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