“Why didn’t anyone tell us?” Why Diagnosis Obligates Prognosis

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Original story posted on: April 4, 2018

It is equally important to know both what disease ails the patient and where it is taking them.

Keen skills in accurately discerning diagnoses is a critical clinical talent that is a source of personal pride for physicians and professional envy by their peers. Being acknowledged as a ‘good diagnostician’ is a peerless reputation to have in the medicine. In the real world of medical practice and in the fake world of TV medicine, an inerrant diagnosis can be both critical and dramatic.

But what about accurately divining prognoses? Prognosis is the often less valued and neglected step-child of diagnosis. Diagnosis tells us what therapy to give to the patient; it is about the beginning of remedying. Prognosis can tell us when to take these treatments away; prognosis may be about the failure of curing. If either one is neglected, it is tragic for the patient. Proper care of a patient requires not only discriminating what the illness is but also crucially discerning its trajectory. It is equally important to know both what disease ails the patient and where it is taking them. Without a credible prognosis, both the physician and the patient are blind to the medical future. Diagnosis obligates prognosis.

Why would diagnosis predominate over prognosis? Medical detection can be difficult but clinical prophecy can be even more challenging. Also, a skillful diagnosis is often perceived as a success even when a malicious malady is uncovered. This can be an exhilarating demonstration of medical acumen. It is also an opportunity to heal a disease and, perhaps, to save a life. Prognosis, especially a poor prognosis, is less enlivening. It often portends the failure of a treatment and the approach of the patient’s demise. An exacting diagnosis can push the limits of proficiency while a doleful prognosis exposes the limits of expertise.

The inability to accomplish a cure may be instinctively felt as a failing of sorts but the reluctance to conscientiously forecast what is incurable is a failure for sure.

One of the most anguished exclamations heard in medicine comes from patients and their loved ones who learn suddenly that the patient has been unwittingly dying for a while. It is five plaintive words that stingingly resonate in the hearer, “Why didn’t someone tell us?This utterance arises out of the searing moment of insight that much of the misery, much of the treatment, and many of the hospitalizations have only prolonged suffering without a chance of remedying the cause – that they have been kept alive but will not have their life restored. It is both the recognition that comfort was a possibility that was not proffered and the poignant realization of being in a bed in a hospital when they could have stayed in their bed at home.

Having death foretold doesn’t engender hopelessness, it sanctions the dying and family to prepare for the end of life. It empowers the dying to take control of their final days. The false assurance of life kindles counterfeit hope, it leaves the dying to be surprised by their own. Making a flawed prognosis is innate in human doctors but not communicating a fatal prognosis is inherently inhuman of physicians.

Prognosis is critical to a patient because it provides predictive information to the sick. Predictive information allows a coping strategy to be formulated by the patient and their caretakers. How to tolerate 24 hours of post-operative pain leading to recuperation significantly differs from enduring months of metastatic hurt ending in death. Not knowing what to expect when a patient is in distress is torment; not being told that dying is approaching when the patient can sense death is torture.

Similarly, prognosis is mandatory for the physician because it, too, provides predictive information. Continuous prognostic surveillance permits the physician to recognize when symptom relief is needed in addition to curative treatment – the need for palliative care. Scrutinizing the course of a sickness authorizes the physician to concede when the patient has been mastered by their disease, when beneficial therapies have been exhausted and compassionate comfort is needed – the time for hospice care.

A failure of diagnosis at the start of a disease causes the patient to suffer unnecessarily but the patient may recover with insightful iatrical reconsideration. But a failure to acknowledge a terminal prognosis causes the patient to gratuitously suffer, leaving death as the only exit from their affliction. It is our obligation as physicians to diligently attempt make both an unerring diagnosis and a plausible prognosis.

Diagnosis allows us to treat precisely; prognosis enables us to comfort properly. Bad news is hard to give and harder yet to receive. But hardest yet is to be left wondering at the very end of life, “Why didn’t anyone tell us?”

Indeed, why didn’t someone?

 

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Michael A. Salvatore, MD, FACP

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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