Evidence-based tools to estimate prognosis and guide goals-of-care discussions. PPI, PPS, and surprise question for cancer. ePrognosis for geriatrics. Prognostication is imperfect -communicate uncertainty honestly.
๐ Overview
Key Prognostic Tools
Tool
Population
What It Predicts
Surprise Question
Any serious illness
"Would I be surprised if this patient died in the next 12 months?" If no โ initiate palliative discussion.
PPS (Palliative Performance Scale)
Cancer and non-cancer
Functional status 0โ100%. PPS โค 50% โ median survival ~6 months. PPS โค 30% โ days to weeks.
PPI (Palliative Prognostic Index)
Cancer
Predicts survival < 3 weeks vs > 6 weeks based on PPS, oral intake, edema, dyspnea, delirium.
3-month mortality in cirrhosis. Transplant prioritization.
Seattle Heart Failure Model
Heart failure
1โ5 year survival in chronic HF based on multiple variables.
Physicians systematically overestimate survival -by a factor of 3โ5ร on average. Use validated tools to supplement clinical judgment. Communicate in ranges, not precise dates.
Key Evidence: Physicians overestimate survival by 3-5x on average Christakis, 2000. The surprise question has ~70% sensitivity/specificity for 12-month mortality Downar, 2017. PPI accurately predicts survival < 3 weeks Morita, 1999. Feeding tubes do not improve survival in advanced dementia Teno, 2012. Functional trajectories differ by disease type and shape prognostic communication Lunney, 2003.
๐จ Management
Communicating Prognosis
Ask before telling: "How much information would you like to know about what to expect?"
Use ranges: "We're talking about days to weeks" or "weeks to months" rather than specific dates
Frame honestly: "I hope for the best, but I'm worried we may be looking at weeks rather than months"
Acknowledge uncertainty: "No one can predict exactly -these are estimates based on what we know"
Functional decline trajectory: Describe what to expect (increasing sleep, decreasing intake, less interaction)
Prognostication itself does not involve medications. When prognosis guides transition to comfort care, see the Code Status & Advance Directives topic for symptom management medications (morphine for pain/dyspnea, lorazepam for anxiety, glycopyrrolate for secretions, haloperidol for agitation).
๐ On Rounds
Pimp Questions
What is the "surprise question" and how accurate is it?
"Would I be surprised if this patient died in the next 12 months?" A negative answer (you would NOT be surprised) identifies patients who would benefit from palliative care discussions. Sensitivity ~70%, specificity ~70%. It performs best as a screening tool -not for precise prognostication, but for triggering earlier goals-of-care conversations. Can be applied to any illness.
Why do physicians consistently overestimate survival?
Multiple cognitive biases: (1) Optimism bias -physicians want patients to do well, (2) Therapeutic optimism -belief that treatment is helping more than it is, (3) Anchoring -to the patient's best functional state rather than current trajectory, (4) Patient expectations -pressure from patients/families who want hope. Studies show physicians overestimate by 3โ5ร on average. Using validated prognostic tools helps counteract these biases.
What is PPS and how do you score it?
Palliative Performance Scale: 0-100% in 10% increments. Based on 5 domains: ambulation, activity/evidence of disease, self-care, intake, and level of consciousness. PPS 50% = mainly sit/lie, unable to work, considerable assistance needed, reduced intake. PPS โค 30% correlates with days to weeks survival.
What are the components of the Palliative Prognostic Index (PPI)?
How do you use the "Karnofsky" vs "ECOG" performance status?
Karnofsky: 0-100 scale (100 = normal, 0 = dead). ECOG/Zubrod: 0-5 scale (0 = fully active, 5 = dead). ECOG is simpler and most used in clinical trials. KPS < 40 or ECOG โฅ 3 suggests limited treatment tolerance and poor short-term prognosis.
What is the trajectory of functional decline in cancer vs organ failure vs dementia?
Cancer: relatively preserved function, then rapid decline in last weeks/months. Organ failure (CHF, COPD): gradual decline with acute exacerbations, each potentially fatal, partial recovery between. Dementia/frailty: slow progressive decline over years. Lunney, 2003. Trajectory shapes communication approach.
What is the "PaP score" and when is it used?
Palliative Prognostic Score: uses dyspnea, anorexia, KPS, clinical prediction of survival, WBC count, and lymphocyte percentage. Divides into 3 risk groups: A (>70% chance of 30-day survival), B (30-70%), C (<30%). Pirovano, 1999. Useful for cancer patients when objective prognostication is needed.
What lab values suggest poor prognosis in advanced illness?
Albumin < 2.5, elevated LDH, leukocytosis, lymphopenia, elevated CRP/inflammatory markers, rising creatinine. Low albumin is the strongest single lab predictor across disease types. Note: albumin reflects inflammation (negative acute phase reactant), not nutritional status per ASPEN 2021.
How do you communicate prognosis when the family asks "How long does he have?"
Use ranges not specific dates: "days to weeks," "weeks to months." Frame with hope and honesty: "I hope for the best, but I'm worried we may be looking at weeks." Offer to explain what to expect functionally. Ask what they need to accomplish in that time. Never say "there's nothing more we can do" - always offer what you CAN do for comfort.
Clinical Examples
๐ Case 1 - Prognostication in Advanced Cancer
Scenario: 78M with metastatic colon cancer, no further chemo options. PPS 40% (mainly in bed, extensive disease, considerable assistance, normal-reduced intake, drowsy). Family asks: "How much time does he have?"
Assessment:
PPS 40% - median survival ~4-6 weeks
PPI: PPS 30-50 (2.5) + reduced intake (1) + no edema (0) + no dyspnea at rest (0) + no delirium (0) = 3.5 - predicts survival > 6 weeks
Clinical trajectory: declining over past 2 weeks, now bed-bound most of day
Lab markers: albumin 2.1, rising LDH - poor prognostic signs
Communication: "Based on what we're seeing, I'm worried we may be looking at weeks to a few months. I hope I'm wrong, but I want to make sure you have time to do the things that matter most to your family."
Teaching point: Use multiple tools (PPS + PPI + clinical trajectory + labs) rather than relying on any single predictor. Convergence of multiple indicators increases confidence.
๐ Case 2 - Prognostication in End-Stage Heart Failure
Scenario: 82F with NYHA Class IV HF, EF 15%, on home inotropes. Third hospitalization in 2 months. Not a transplant or LVAD candidate. Surprise question: "No, I would not be surprised if she died in the next 12 months."
Recurrent hospitalizations despite optimized GDMT - marker of end-stage trajectory
NYHA IV + inotrope dependence - median survival 6-12 months without advanced therapies
Functional trajectory: organ failure pattern with stepwise decline and incomplete recovery between exacerbations
Communication: "Her heart is getting weaker despite our best treatments. Each hospitalization is harder to recover from. I think we're looking at months rather than years. I want to make sure we're focusing on what matters most to her."
Teaching point: Heart failure prognostication is harder than cancer because of the unpredictable exacerbation pattern. Patients may die suddenly from arrhythmia even when "stable." Use the surprise question to trigger earlier GOC discussions.
๐ Case 3 - Prognostication in Advanced Dementia
Scenario: 89F with advanced Alzheimer's, FAST stage 7C (nonambulatory, minimal verbal, requires total care). Recurrent aspiration pneumonia. Nursing home asks about feeding tube placement.
Assessment:
FAST 7C - median survival ~12 months (range 6-24 months)
Recurrent aspiration pneumonia in advanced dementia - 6-month mortality ~50%
CASCADE study: feeding tubes do NOT prevent aspiration, do NOT improve survival, and increase agitation in advanced dementia
Functional trajectory: slow progressive decline typical of dementia/frailty trajectory
Communication: "Your mother's dementia has reached an advanced stage where her body is losing the ability to swallow safely. A feeding tube would not prevent aspiration and studies show it doesn't help people with advanced dementia live longer. I'd recommend we focus on careful hand feeding for comfort and pleasure, and discuss what your mother would have wanted."
Teaching point: The Choosing Wisely campaign and multiple studies recommend against feeding tubes in advanced dementia. This is one of the clearest evidence-based recommendations in palliative care. Frame as what you CAN do (hand feeding, comfort), not what you won't do.
โก Summary
Surprise Question
"Would I be surprised if they died in 12 months?" If no โ palliative discussion. Screening tool.
PPS
Palliative Performance Scale 0-100%. โค50% โ ~6mo median. โค30% โ days to weeks.
Physician Bias
Physicians overestimate survival 3-5ร. Use validated tools. Communicate in ranges.