Journal of Gerontological Nursing

AGS Update 

In the Latest Update to the GNRS6, Prognostication Comes of Age: Here's Why That Matters

Sunny Linnebur, PharmD, FCCP, FASCP, BCPS, BCGP

Abstract

How often do we hear the question, “How much time does mom have?,” in our work with older adults? For many members of the American Geriatrics Society, the question comes up almost daily—and yet that never makes answering the question any easier, does it?

In his best-selling memoir, When Breath Becomes Air, Paul Kalanithi (2016) offers a clue on why answering this question is complicated:

Science…may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: Hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.

In short, discussing “how much time” someone has takes many clinicians too far from the comfort zones of research, clinical practice, and public policy. Ultimately, we know asking has less to do with time as an empirical and more to do with time as an inability to grasp the most central aspects of human life.

But that does not preclude older adults and caregivers from asking—and it cannot (and should not) preclude us from developing the science (and art) of responding. A subtle—but, I would argue, powerful—change to one of our core texts for nurses deserves to be celebrated for helping push that work forward.

With the release of the Geriatric Nursing Review Syllabus, 6th Edition (GNRS6), a new addition to the chapters covering approaches to patients was added: Prognostication (Lo & Widera, 2019).

The concept—and even the science behind it—is familiar, perhaps deceptively so. As defined in the GNRS6, prognostication is a broad term for “estimating and communicating prognosis,” the “probability that a particular outcome will develop in an individual over a period of time” (Lo & Widera, 2019, p. 30). For a field like geriatrics, which so often meets patients who have lived for years with care conditions and concerns, prognosis is something we know well.

And thankfully, years of research and experience have led to expertise in four key methods highlighted in the GNRS6:

But as the GNRS6 points out in this new chapter, prognosis and communicating prognosis play a central role in care—one that ultimately informs the expertise covered in the remaining 66 chapters of the text (Lo & Widera, 2019).

Estimating prognosis for patients with cancer, for example, has rapidly accelerated in recent history thanks to an abundance of published studies (Lo & Widera, 2019). New chemotherapies and other treatments have dramatically improved life expectancy and also added greater accuracy to questions about treatment benefits. Yet, the generalizability of this research to older adults remains challenging, as complex older adults have often been excluded from clinical trials because of functional declines, cognitive limitations, and comorbidities.

In a field like oncology, which has celebrated broad but critical progress as of late, clinicians working with older adults and caregivers still face challenging questions about “promising” approaches with little evidence addressing older adults (Lo & Widera, 2019). What is more, incorporating the concept of lag time to benefit in these evaluations may be particularly key for clinicians addressing prognosis for patients with advanced age (Lo & Widera, 2019). If a patient's life expectancy is significantly less than the lag time to benefit of a preventive intervention, the likelihood a patient could be harmed rather than helped is not only high but also critical to make clear—and to make clear through prognostication (Lo & Widera, 2019). Such considerations also become more and more important as prognostication intersects with person-centered care and what “matters most” to an older adult beyond what best-practice guidelines might recommend. Indeed, one characteristic that has helped set geriatrics…

How often do we hear the question, “How much time does mom have?,” in our work with older adults? For many members of the American Geriatrics Society, the question comes up almost daily—and yet that never makes answering the question any easier, does it?

In his best-selling memoir, When Breath Becomes Air, Paul Kalanithi (2016) offers a clue on why answering this question is complicated:

Science…may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: Hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.

In short, discussing “how much time” someone has takes many clinicians too far from the comfort zones of research, clinical practice, and public policy. Ultimately, we know asking has less to do with time as an empirical and more to do with time as an inability to grasp the most central aspects of human life.

But that does not preclude older adults and caregivers from asking—and it cannot (and should not) preclude us from developing the science (and art) of responding. A subtle—but, I would argue, powerful—change to one of our core texts for nurses deserves to be celebrated for helping push that work forward.

With the release of the Geriatric Nursing Review Syllabus, 6th Edition (GNRS6), a new addition to the chapters covering approaches to patients was added: Prognostication (Lo & Widera, 2019).

The concept—and even the science behind it—is familiar, perhaps deceptively so. As defined in the GNRS6, prognostication is a broad term for “estimating and communicating prognosis,” the “probability that a particular outcome will develop in an individual over a period of time” (Lo & Widera, 2019, p. 30). For a field like geriatrics, which so often meets patients who have lived for years with care conditions and concerns, prognosis is something we know well.

And thankfully, years of research and experience have led to expertise in four key methods highlighted in the GNRS6:

  • Making clinical judgments—the process of building and evaluating past patient experiences to predict future outcomes.
  • Evaluating age-based life expectancy—a method vested in finding “data-driven starting points” to estimate prognosis based on what we know about median survival rates for the general population (Lo & Widera, 2019, p. 31).
  • Reviewing published studies—another data-driven approach, but one that seeks to provide “a more accurate and individualized prognosis” by linking published reports to patients who exhibit similar characteristics (Lo & Widera, 2019, p. 31).
  • Consulting prognostic indices—leveraging validated tools that do much of the leg work for us by calculating outcome estimates based on patient characteristics (Lo & Widera, 2019).

But as the GNRS6 points out in this new chapter, prognosis and communicating prognosis play a central role in care—one that ultimately informs the expertise covered in the remaining 66 chapters of the text (Lo & Widera, 2019).

Estimating prognosis for patients with cancer, for example, has rapidly accelerated in recent history thanks to an abundance of published studies (Lo & Widera, 2019). New chemotherapies and other treatments have dramatically improved life expectancy and also added greater accuracy to questions about treatment benefits. Yet, the generalizability of this research to older adults remains challenging, as complex older adults have often been excluded from clinical trials because of functional declines, cognitive limitations, and comorbidities.

In a field like oncology, which has celebrated broad but critical progress as of late, clinicians working with older adults and caregivers still face challenging questions about “promising” approaches with little evidence addressing older adults (Lo & Widera, 2019). What is more, incorporating the concept of lag time to benefit in these evaluations may be particularly key for clinicians addressing prognosis for patients with advanced age (Lo & Widera, 2019). If a patient's life expectancy is significantly less than the lag time to benefit of a preventive intervention, the likelihood a patient could be harmed rather than helped is not only high but also critical to make clear—and to make clear through prognostication (Lo & Widera, 2019). Such considerations also become more and more important as prognostication intersects with person-centered care and what “matters most” to an older adult beyond what best-practice guidelines might recommend. Indeed, one characteristic that has helped set geriatrics apart is a sensitivity to how these lines of inquiry are interconnected, and how to address them as mutually inclusive rather than exclusive (The Conversation Project, 2019; PREPARE™ For Your Care, 2019).

For current and future generations of advanced practice nurses, pharmacists, physicians, physician assistants, social workers, and other professionals, adding prognostication to a text such as the GNRS6 acknowledges new frontiers where we are accelerating our understanding and approach to care. And as we continue to wrestle with new science and old discomfort when it comes to the question “How much time does mom or dad have?,” dedicating time and attention to the intersection between prognosis and prognostication will be key to forward momentum.

We will likely always live with a space separating “science” from its “inability to grasp the most central aspects of human life,” (Kalanithi, 2016, p. 170) but perhaps advancing how we discuss the distance between the two can make us—and our patients—more comfortable with what we know…and what we don't.

For more information on the GNRS6, access GeriatricsCareOnline.org.

Sunny Linnebur, PharmD, FCCP,
FASCP, BCPS, BCGP
President
American Geriatrics Society

References

  • The Conversation Project. (2019). About us. Retrieved from https://theconversationproject.org/about
  • Kalanithi, P. (2016). When breath becomes air (1st ed.). New York, NY: Random House.
  • Lo, D. & Widera, E. (2019). Prognostication. In Resnick, B. (Ed.), Geriatric nursing review syllabus (6th ed., pp. 30–33). New York, NY: American Geriatrics Society.
  • PREPARE™ For Your Care. (2019). The PREPARE for your care story. Retrieved from https://prepareforyourcare.org/story
Authors

The author has disclosed no potential conflicts of interest, financial or otherwise.

10.3928/00989134-20191011-07

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