Prognosestellung bei schwer kranken Menschen

Zusammenfassung

Die Prognose von Überlebenszeit stellt ein sehr herausforderndes und ethisch empfindliches Thema im Rahmen des Umgangs mit schwer kranken und sterbenden Menschen dar. Die Frage „Wie viel Zeit bleibt noch?“ beinhaltet ganz unterschiedliche Facetten, die für den Lebens- und Behandlungskontext des betroffenen Patienten essenziell sind. Auch vonseiten der Behandler spielt die Einschätzung der Überlebenszeit eine wichtige Rolle bei therapeutischen Entscheidungen.

Der klinische Eindruck des Arztes führt allerdings bei 80 % der Tumorpatienten zu einer sehr ungenauen Einschätzung. In den meisten Fällen wird die verbleibende Lebenszeit zu optimistisch bewertet und dabei bis um das 5-Fache überschätzt.

Im deutschen Sprachraum wird vorwiegend Gebrauch von zwei Messinstrumenten gemacht: dem Palliative Prognostic Index (PPI) und dem Palliative Prognostic Score (PaP-S). Allerdings ist nicht klar, ob die Aussagekraft dieser Instrumente für die Beurteilung des individuellen Patienten ausreichend ist oder ob der Wert der Instrumente eher in der Beschreibung von Patientengruppen liegt.

In der klinischen Praxis empfiehlt sich deshalb die „Überraschungsfrage“, die sowohl für längere wie auch für kürzere Zeiträume zumindest einen klaren Warnhinweis geben kann, bei welchen Patienten die Überlebenszeit vielleicht viel kürzer als gedacht ist. Der Behandler stellt sich die Frage: „Würde es mich überraschen, wenn der Patient im nächsten Jahr/in der nächsten Woche/in den nächsten Stunden verstirbt?“ Wird diese Frage mit „Nein, es würde mich nicht überraschen“ beantwortet, ist die Wahrscheinlichkeit hoch, dass der Patient tatsächlich in diesem Zeitraum versterben wird. Die Überraschungsfrage lässt sich durchaus auch für nicht tumorbedingte Erkrankungen sinnvoll einsetzen, bei denen die Prognose-Scores nicht ausreichend getestet sind, und erlaubt es dem Behandler, die Kommunikation und Therapieplanung auf die Prognose des Patienten abzustimmen.

Abstract

Prognosis of the remaining life time is challenging and may be ethically problematic in the care of severely ill or dying patients. The question “how much time do I have left?” includes a range of different aspects that might be essential within the context of the patient’s life. Health care professionals need to answer that question as well, as it has a major role in treatment decisions.

Prognosis based on the clinical knowledge of the physician is overly optimistic in 80 % of cases, often overestimating survival times by the factor of five. In the German language area two prognostic instruments have been used in palliative care: the Palliative Prognostic Index (PPI) and the Palliative Prognostic Score (PaP-S). However, it is not clear whether the value of these instruments is for the evaluation of patient groups rather than individual patients.

In clinical practice the use of the “surprise question” is recommended, as it can provide a warning for shorter as well as for longer time frames which patients may have shorter survival times than previously assumed. The physician asks himself “Would I be surprised if this patient dies in the next year/next week/next hours?” If this is answered with “No, I would not be surprised” the probability is high that the patient will die within this time range. The surprise question can also be used for non-cancer diseases where the prognostic scores have not been tested adequately, and it enables the health care professionals to align communication and care planning with the prognosis of the patient.

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