Not that long ago, Juliet Jacobsen, MD, had for a patient a woman with cancer. The patient did not want Jacobsen to talk about life expectancy. At all. Ever. She did not want to talk about time-based prognosis when she was diagnosed. She did not want to talk about it when cancer spread. 

She did not want to discuss it when she stopped treatment or enrolled in hospice. The same was true when she signed a do-not-resuscitate order.

"We were able to make all those decisions without her having to know if she had 6 months, 3 months, or 3 days left," said Jacobsen, of Massachusetts General Hospital, Brigham and Women's Hospital, and the Harvard School of Public Health, in Boston. "The idea that you have to have specific information to have decision-making conversations" just is not true.

And that's good news because two recent articles suggest that discussing life expectancy and prognosis are tough on both sides of the doctor-patient relationship. And that means, suggest palliative care specialists, that physicians may need to redefine what a successful prognosis discussion looks like, using shared decision making and patient-centered approaches.

Life Expectancy? No Thanks

If we are going to talk patient-centered, it's important to know what patients want. Therefore, Nancy Schoenborn, MD, of the Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues asked more than 1000 older adults with chronic illnesses when and how they wanted to talk to physicians about life expectancy.

These are her patients, said Schoenborn, a primary care physician who works with people who are "older and often sicker and at various points of this decline toward the end of life." The study was published in the November/December issue of the Annals of Family Medicine.

What she found was that 59.4% of the 878 respondents did not want to talk about life expectancy at all if life expectancy was 10 or more years. And 87.7% did not want physicians talking to family or friends about it either.

Patients' interest changed, however, when life expectancy dropped to 2 years. Then, 55.8% of patients wanted their doctor to talk to them about it. Still, like Jacobsen's patient, 16.5% of respondents didn't want to talk about life expectancy even when it dropped to 1 month.

This all made sense to Schoenborn, in a way, after all, people with chronic conditions who are not facing something like cancer don't necessarily need to have these conversations. They are important for physicians, however, as they have a bearing on some preventive screenings 10 years from the end of life.

What did surprise her was the answer to another question: Would patients be open to a physician asking if the patient wanted to have the discussion? Nearly 60% of patients said absolutely not.

"Before this study, that is what we were proposing," she said "telling patients, 'This is something we ask everyone about, is it OK if we ask you if you're open to the conversation?' " The answer left her wondering, "If a patient doesn't want to be offered, what is a clinician to do?"