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Imminent death: Clinician certainty and accuracy of prognostic predictions

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Title: Imminent death: Clinician certainty and accuracy of prognostic predictions
Authors: White, N
Reid, F
Vickerstaff, V
Harries, P
Tomlinson, C
Stone, P
Item Type: Journal Article
Abstract: Objectives To determine the accuracy of predictions of dying at different cut-off thresholds and to acknowledge the extent of clinical uncertainty. Design Secondary analysis of data from a prospective cohort study. Setting An online prognostic test, accessible by eligible participants across the UK. Participants Eligible participants were members of the Association of Palliative Medicine. 99/166 completed the test (60%), resulting in 1980 estimates (99 participants × 20 summaries). Main outcome measures The probability of death occurring within 72 hours (0% certain survival−100% certain death) for 20 patient summaries. The estimates were analysed using five different thresholds: 50/50%, 40/60%, 30/70%, 20/80% and 10/90%, with percentage values between these extremes being regarded as ‘indeterminate’. The positive predictive value (PPV), negative predictive value (NPV) and the number of indeterminate cases were calculated for each cut-off. Results Using a <50% versus >50% threshold produced a PPV of 62%, an NPV of 74% and 5% indeterminate cases. When the threshold was changed to ≤10% vs ≥90%, the PPV and NPV increased to 75% and 88%, respectively, at the expense of an increase of indeterminate cases up to 62%. Conclusion When doctors assign a very high (≥90%) or very low (≤10%) probability of imminent death, their prognostic accuracy is improved; however, this increases the number of ‘indeterminate’ cases. This suggests that clinical predictions may continue to have a role for routine prognostication but that other approaches (such as the use of prognostic scores) may be required for those cases where doctors’ estimates are indeterminate.
Issue Date: 25-Nov-2022
Date of Acceptance: 22-Apr-2019
URI: http://hdl.handle.net/10044/1/70134
DOI: 10.1136/bmjspcare-2018-001761
ISSN: 2045-435X
Publisher: BMJ
Start Page: e785
End Page: e781
Journal / Book Title: BMJ Supportive & Palliative Care
Volume: 12
Issue: 6
Copyright Statement: © 2019 Author(s) (or their employer(s)). Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Publication Status: Published
Online Publication Date: 2019-05-10
Appears in Collections:Department of Metabolism, Digestion and Reproduction
Faculty of Medicine
Faculty of Natural Sciences