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tients are increasing our interest in predicting death and its timing. Patients and families have become more involved in making medical decisions and often need better information about their medical situation and the likely consequences of different treatment options. Meaningful involvement in medical decision making for patients and families implies access to meaningful information about expected outcomes. Meaningful involvement is especially important for those with complex chronic medical problems. Another reason for the interest in prognosis is that laws or regulations make access to some kinds of care contingent on estimates of life expectancy. For example, to qualify for hospice benefits, a Medicare or Medicaid beneficiary must be certified as having less than six months to live. Similarly, Oregon’s assisted suicide statute links legal access to prescriptions of lethal drugs to a six-month life expectancy (among other criteria).1 Statements in “living wills” or advance care directives about preferences for CPR or other life-sustaining interventions may be phrased in terms of expectations about survival or other outcomes (e.g., cognitive capacity). In addition, the development and wide deployment of advanced medical technologies in recent years has prompted concern about possibly futile uses of these technologies for those who die.2,3
Pediatric decision making involves special circumstances. The child patient has limited legal autonomy, and capacity to make reasoned decisions that varies with a child’s developmental level. Nonetheless, many pediatricians believe that children’s views ought to be taken into account, which can present problems, especially in the case of older adolescents. Family and societal values are complex and sometimes incline toward exhausting every life-prolonging option, perhaps without full appreciation of the burdens imposed on the child. Such a decision to continue life-prolonging treatment far beyond the recommendations of health care professionals is also a severe stress to the health care institution and staff when it occurs. Children cannot be left out of the current efforts to insure that people die with as much dignity as possible and that decisions about care be based on the appropriate scientific evidence and clinical experience.
Could prognostication tools and quantitative estimates or scores help clinicians? The following discussion considers the preparedness of physicians to undertake complex life and death decisions, the elements of quantitative prognostic tools and scores, the accuracy of clinicians’ estimates, and issues in using prognostic scores to guide decisions about individual patients.
THE LACK OF PREPAREDNESS
Despite the interest in prognostication and its application to end-of-life decisions, educational experiences and resources for health care profession-