|
|
Slender, in her 60s and possessing the stoicism of someone who had single-handedly raised children in the toughest section of the city, our patient faced a difficult challenge of the medical kind. She had diabetes and such severe peripheral vascular disease that even the strongest antibiotics could not heal a long-standing foot infection. She needed an operation.
This grandmother who regularly held court in her hospital room with her extended brood also suffered from high blood pressure and heart disease, and all of us on the surgical team knew that operating would be no easy feat. We could amputate her infected foot, a relatively quick operation that would carry few risks, but she would never walk again. Or we could do an arterial bypass, a more complex operation that would save her leg but that might disable or even kill her before her surgical scars ever healed.
The final decision hinged on our assessment of her likely course, or prognosis. If she was unlikely to live long, we would amputate, because it wouldn't make sense to put her at risk of other life-threatening complications just to save her leg. But to throw out some ballpark figure, an actual number of the weeks, months or years this woman we had grown to care about had left to live, meant shouldering the responsibility none of us were eager to be reminded of - that is, our potential role in hastening her death because of poor clinical decisions based on the wrong prognosis.
A week after her bypass operation, our patient died of a heart attack. The prognosis of her senior surgeon and our entire team -- that she would tolerate the surgery and survive long enough to walk again -- had been incorrect.
While not all assessments of how long someone has to live result in life-or-death clinical decisions, addressing prognosis remains a challenge for most doctors. And after struggling for several years with determining their own patients' prognoses, a group of physicians at the University of California in San Francisco set out to collect and study all the research that had been done on so-called prognostic indexes, tools that help with determining general prognosis in older patients.
Given the growing use of age-based treatment and preventive care guidelines, the doctors assumed there would be plenty of data to help decide whether, for example, an 80-year-old patient might live long enough to benefit from a colonoscopy, a cancer screening procedure that can have its own set of complications.
But they found little.
Click here to read more.
