In response to research revealing the importance of prognostic conversations and low patient recall of prognostic conversations, Margaret Isaac, MD and Randall Curtis, MD outlined a systematic approach for this patient communication.1 Their Ask-Tell-Ask technique serves as a method for discovering patient preferences regarding prognostic disclosure, communicating prognostic information, and assessing comprehension. Doctors Isaac and Curtis presented this approach as a remedy for challenges in patient care:
- The majority of patients in advanced disease states want to know their life expectancy, but only a minority of patients recall having such conversations with their doctors. 2-4 In one survey of patients with advanced cancer, 71% of participants expressed a desire to know their prognosis, but only 18% recalled having such a conversation with a clinician.2
- Patient recall of prognostic conversations can be poor. Among patients whose charts document a prognostic disclosure, nearly half of patients report not having a prognosis conversation.5
- Patient recall of end-of-life discussions correlates with higher quality of life for patients and improved bereavement outcomes for caregivers.6
Here, we describe the Ask-Tell-Ask approach in four steps:
1. Ask: Ask the patient to describe his/her understanding of the disease and prognosis (“Can you tell me what you already know about your disease and what your other doctors have already told you?”). This step not only helps physicians determine what patients have learned elsewhere, it may also help physicians determine the retention of information they themselves have already presented.
2. Ask: Determine each patient’s preference for receiving prognostic information. This may be more than a “yes” or “no” question. Fried and colleagues found that patients who individually believed they had a prognosis of one year or less were more likely to want prognostic information.7 It may be advantageous for patients to explore certain conditions under which they may want to know their prognostic information (e.g. “If there were a chance of death within 1 year, 2 years, or 3 years, would you want to know?”).
3. Tell: Provide the prognostic information patients want or need to make informed decisions about medical planning. John Paling states that patients understand risk better when doctors provide percentages expressed in terms of x out of 100 versus a straight percentage figure and versus descriptive terms such as “low risk.”8 Paling also states that patients will retain the information better if the same risk is expressed as both a positive and a negative. For instance: “Among patients with conditions similar to yours, 25 out of 100 will die within one year and 75 out of 100 will be alive at one year.” Kutner and colleagues found that 100% of patients wanted their clinicians to be honest with them while 91% of the same patients wanted their clinicians to be optimistic.9 When doctors need to state a negative, such as the absence of a known cure, they can follow it with a positive such as the options for symptom control, improving longevity, and maximizing quality of life.
4. Ask: Assess the patient’s understanding. “I want to make sure that I explained things clearly. Can you tell me in your own words what I just told you about your disease?”
When patients have potentially life-limiting illnesses, the Ask-Tell-Ask technique holds promise for satisfying both patients who do and don’t want prognostic information and for overcoming the issue of patients not recalling information provided.
Extending the Conversation Into the Home
When prognostic conversations reveal a need for additional support, Avatar Home Health & Hospice helps physicians translate care goals into appropriate services at home. Our comprehensive continuum includes skilled home health, palliative care, hospice, and personal assistance services for patients throughout Greater Houston and The Woodlands.
Avatar’s nurses and interdisciplinary professionals reinforce physician guidance, support symptom management, monitor changing needs, and help patients and families navigate the next stage of care. Our bilingual staff can further support clear communication for Spanish-speaking patients and families.
We respond to referrals within 24 hours—and typically within 30 minutes when received Monday through Friday from 8:30 a.m. to 5:30 p.m. To discuss eligibility or refer a patient, visit our referral page or call (281) 465-8220.
References
- Isaac M, Curtis J. Improving quality of life for patients with terminal respiratory disease. Expert Review of Respiratory
Medicine. 2009; 3 (6): 597-605. - Enzinger A, Zhang B, Schrag D, Prigerson H. Outcomes of prognostic disclosure: associations with prognostic un- derstanding, distress, and relationship with physician among patients with advanced cancer. J Clin Oncol. 2015; doi. 10.1200/JCO.2015.61.9239.
- Fried T, Bradley E, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers,
and clinicians. Journal of the American Geriatric Society. 2003; 51 (10): 1398-1403. - Daugherty C, Hubocky F. What are terminally ill cancer patients told about their expected deaths? A study of cancer
physicians’ self-reports of prognosis disclosure. J Clin Oncol. 2008; 26: 5988-5993. - Fried T, Badley E, O’Leary J. Prognosis communication in serious illness: perceptions of older patients, caregivers,
and clinicians. Journal of the American Geriatric Society. 2003; 51 (10): 1398-1403. - Wright A, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008; 300 (14): 1665-73.
- Fried T, Bradley E, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. Journal of the American Geriatric Society. 2003; 51 (10): 1398-1403.
- Paling J. Strategies to help patients understand risks. Br Med J. 2003; 327: 745-748.
- Kutner J, Steiner J, Corbett K, et al. Information needs in terminal illness. Soc Sci Med. 1999: 48: 1341-1352.
