Prognostic tools or clinical predictions: Which are better in palliative care?

P Buckle,C Todd,K Spencer,P Stone,R Z Omar,V Keeley,V Vickerstaff,Tim Luckett,D Finlay,J Griffiths,A Kalpakidou

doi:10.1371/journal.pone.0249763

Abstract

PurposeThe Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS).MethodsThis was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse.ResultsPrognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups.ConclusionsAlthough four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.

Highlights

Prognostic information is essential for informing decision-making at the end of life
All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to clinical predictions of survival (CPS). Both Palliative Prognostic (PaP) and CPS were able to accurately categorise patients according to their risk of dying within 30 days
There was no difference in performance between CPS and Feliu Prognostic Nomogram (FPN) at stratifying patients according to their risk of dying at 15, 30 or 60 days

Summary

Introduction

Prognostic information is essential for informing decision-making at the end of life. Patients’ understanding about their prognoses is often inaccurate and over-optimistic [1,2,3,4,5] Patients expect their physicians to provide them with honest accurate and realistic estimates of survival [6,7]. Clinicians’ estimates are frequently better than patients’ own predictions [1,5], they still tend to be inaccurate [8,9]. For this reason physicians are encouraged to supplement their clinical intuition with validated prognostic algorithms [10,11]. The performance of relatively few of these tools has been compared against clinicians’ own predictions of survival [14,15,16,17,18]

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Conclusion