Expanding the Prognostic “Tool Kit”: a response to Loh et al

We greatly appreciate the response of Loh et al. to our editorial, “Why Many Oncologists Fail to Share Accurate Prognoses: They Care Deeply for Their Patients [1].” Loh et al. emphasize the difficult reality of prognostic disclosures, and their focus on physician self-awareness is a welcome expansion to our original “tool kit.” Additionally, we welcome the idea that attention must be paid to fully understanding the patient’s support network. While these points are consistent with our editorial, we agree that an all-encompassing prognostic tool kit could emphasize these points to a greater degree.

First, the importance of physicians’ self-awareness through the process of sharing bad news is a key piece of the SPIKES protocol, which we mentioned as a useful tool for prognostic disclosure, though we did not go into detail. The S step in this process - Setting up the conversation - encompasses the physician’s mental preparation and rehearsal for the conversation, including the realization that being the messenger of bad news comes with the expectation of negative feelings and frustration or potential feelings of responsibility [2]. This step helps balance these negative feelings with the fact that the information can help the patient plan for their future treatment options.

Loh et al. also suggest that physicians be kind and honest to patients. This point is the heart of our original editorial: We believe oncologists are genuinely kind and care deeply for their patients, making disclosing prognoses in an honest manner more difficult. As there is a wide range of potential patient responses to prognostic disclosure, the E step of SPIKES focuses on identifying the patient’s emotions and how physicians may best navigate providing empathetic responses. A proper, human response can lower the patient’s feelings of isolation and validate their feelings of sadness, disbelief, or anger as normal and okay to experience. We recommend that physicians use these tools to mitigate the emotional distress both in patients and in themselves, just as they should use tools that provide more numerical accuracy to prognostic timelines. Using these tools can also help physicians be kind and honest with themselves as Loh et al recommend. Akin to Al-Samkari’s recommendation, we agree that self-awareness could be added to physician training and evaluated more formally [3].

We also applaud and agree with Loh’s concluding paragraphs that focus on the difficulties patients have with prognostic understanding, especially in older populations that may have unique cognitive impairments. The preference tool we recommended, designed to inform the physician’s recommendation, included questions regarding whether a family member (husband/wife, son/daughter) helped fill out the patient preference tool to acknowledge family input. The preference tool was also carefully designed in order to be patient friendly without complicated terms or percentages and easy to use with patients (or their families) from all backgrounds. Preferences that were listed were simple, like “Avoiding extra travel and time away from home” [4]. While true that patients’ decision making may be a “black box,” developing a simple prognostic preference tool that includes input from the patient’s support network could let the physician know what this patient wishes to know about their prognosis. Overall, we do agree that more research is needed to best incorporate the input of family and friends in influencing patient preferences.

Our hope is that this continued discussion about the uncomfortable components of timely disclosure of prognoses will lead to a more developed “tool kit” for physicians and promote supplemental resources and training to aid both physicians’ management of their own psychological distress and methods of empathetic communication with their patients.