Murray and colleagues were the first to suggest that clinicians might take to prevaricating on end of life issues, when faced with prognostic uncertainty, a phenomenon more likely to be encountered in non-malignant diseases.

The absence of a prognostic estimate might lead clinicians to defer decisions related to advanced care planning, palliative care referrals and goals of care conversations. The model of care delivery based upon expected trajectory in cancer palliative care might not be suited to other chronic life-limiting diseases which are expected to be characterized by a progressive decline with periods of exacerbations and remissions (without a return to pre-morbid baseline). The situation is compounded by the cultural conditioning that feels obliged to consider palliation as the antithesis of acute care.

While illness trajectories might serve as conceptual frameworks, it is important to acknowledge that their applicability is marred by a lack of precision. There is growing evidence that even the sudden terminal decline expected in advanced cancer is punctuated by periods of improvements and return to a sub-optimal baseline.

Tools such as SPICT, Surprise question and Gold standards framework which are used as triggers for a referral identify this imprecision (prognostic uncertainty) and are intended to act as the first step in decoupling palliative referrals from prognosis.

Parallel planning, anticipatory palliative care, avoidance of the binary approach of cure versus care and acknowledgement of uncertainty are also advised to counter prognostic paralysis.

References

Murray, S. A., Boyd, K., & Sheikh, A. (2005). Palliative care in chronic illness: We need to move from prognostic paralysis to active total care. BMJ, 330(7492), 611–612. https://doi.org/10.1136/bmj.330.7492.611

Murray, S. A., Kendall, M., Boyd, K., & Sheikh, A. (2005). Illness trajectories and palliative care. BMJ, 330(7498), 1007–1011. https://doi.org/10.1136/bmj.330.7498.1007

Royal College of Physicians. (2018). Talking about dying: How to begin honest conversations about what lies ahead. RCP. https://www.rcplondon.ac.uk/projects/outputs/talking-about-dying

#Existential finitude|