Direct observation of prognosis communication in palliative care: A descriptive study

Context: Palliative care (PC) consultations result in improved patient understanding of prognosis and better quality of life, yet the content and processes of prognosis communication during PC consultations remain unknown. Objectives: To describe prognosis communication during PC consultation with seriously ill hospitalized patients. Methods: We audio recorded 71 sequential inpatient PC consultations (initial visit) with seriously ill patients and their families who were referred for "goals of care" clarification or help with "end-of-life decision making." Conversations were coded using reliable methods and we then linked conversation codes to clinical record and clinician interview data. Results: Ninety-three percent of consultations contained prognosis communication. Participants communicated prognoses regarding quality of life more frequently than survival; focused prognosis estimates on the unique patient more frequently than on a general population; and framed prognosis using pessimistic cues more frequently than optimistic ones. Prognoses were more commonly spoken by PC clinicians than by patients/families. The following two factors demonstrated an association with the rate of prognostic communication and with the pessimistic framing of that information: whether the patient, family, or both participated in the conversation, and shorter expected survival (as estimated by the attending physician). Conclusion: Prognoses are routinely communicated in PC consultations with hospitalized patients and their families. The rate and characteristics of prognosis communication differ based on the length of time the patient is expected to live.