Post 24: A Cloudy Crystal Ball - Predictors of Prognosis Part 1 of 3
Updated: Nov 30, 2022
What do you have trouble doing now that you could easily do for yourself before?
Sometimes a person with a concerning diagnosis or serious illness asks, "How am I doing?" which may be another way of asking "Do you think I'll be okay and at least continue the way I am?" or "What do I need to be concerned about?" (read Post 15: What's My Heaven ETA? - The Who, What, Where, When, Why, and How in Asking About Prognosis).
A meaningful response beyond "You're okay. You're fine!" requires first asking the following questions, that either a healthcare provider may ask or a person (or family member) may ask themselves, about daily self care activities.
(In Post 26: A Cloudy Crystal Ball - Predictors of Prognosis Part 2 of 3, I explain the significance of the question, "How has your weight changed in the past year?" and in Post 28: A Cloudy Crystal Ball - Predictors of Prognosis Part 3 of 3, I explain the significance of the question "How do you spend most of your day?").
Question #1 What are you able to do for yourself now, specifically for daily self care?
The following are the "activities of daily living" or ADLs that healthcare providers question to help determine how a person is doing.
Transferring (that is, moving from one body position to another) Are you able to slowly swing your legs over the side of the bed, grip your walker, and steadily stand? If you wanted a drink of water, could you easily step up from a chair and take a step? Are you able to smoothly step into and sit in a car and place your cane on the passenger side floor?
Or does your spouse pull you up in bed? Does your spouse hold you steady as you drop first one leg, then the other over the side of the bed to stand up? When you are in your recliner and want to walk to the kitchen, does your son hold his arm out for you to hold onto as you stand up? Can you only stand on your own from a lift chair and would otherwise need your son nearby to assist with standing?
Walking ("ambulating") Do you feel steady and comfortable taking steps, walking from end of the hallway to the other? On your own, with a cane, or with a walker, do you and your family feel comfortable with your walking around the house without supervision?
Or do you feel hesitant about your balance? Do you worry about your legs giving out, perhaps from sciatica pain, knee pain, "heavy legs," or fatigue? Have you fallen or are anxious about falling? Does your family feel this way?
Bathing (and grooming) Are you able to step in the shower easily and shower on your own? Sometimes a shower chair, grab bars, long handle bath sponge, and handheld shower will allow a person to shower safely on their own. Do you brush your teeth, brush your hair, or shave without help?
Or do you hold onto your spouse as you step into the shower? Does your daughter stand just outside the bathroom in case you call out for help? Does a home health aide shampoo and rinse your hair for you? Does it now take one hour to complete your bath when it used to take thirty minutes?
Dressing Are you able to pick out your own clothes, with or without using a reacher (also called a "grabber"? Do you put on your shirt, underwear, pants, socks, and shoes on your own, with or without using a dressing stick, reacher, sock aid, or long handle shoe horn?
Or does your spouse now pick out your clothes because you confused pajamas for winter clothes? Does your spouse help you put on your shirt because you cannot raise your left arm much? Does your son help you put on your socks and shoes because you feel dizzy whenever you bend over? Does it now take one and a half hours to get dressed when it used to take thirty minutes?
Toileting Are you able to get up and walk to the bathroom, sit on the toilet (with or without a toilet riser), wipe, pull up your underwear and pants on your own?
Or do you wait for your spouse to walk with you to the bathroom? Do you hold onto your spouse as you sit down on the toilet or get up from the toilet? Does your daughter help you wipe and clean yourself? Does your daughter help pull up your pants?
Feeding Are you able to get food from the plate to your mouth, with any type of utensil or modified utensil, on your own?
Or does your spouse now hold the straw to your mouth? Does your granddaughter lift the utensil to your mouth?
Question #2 What has changed from 3 months ago, 6 months ago, or 12 months ago?
Changes and the rate of change is a big predictor of a person's health trajectory and prognosis.
A 73 year old person with dementia requiring help for bathing and dressing - the same amount of assistance for the past two years - would be considered to have a stable big picture and an unknown health trajectory of either more of the same versus the start of a notable decline within the next year.
A 73 year old person with dementia requiring help for bathing and dressing - who had been completely independent and driving six months ago - would be considered to have a concerning big picture with a likely health trajectory of continued decline within the next year.
A person's diagnosis does play a factor. If a person's need for help with walking, bathing, dressing, and toileting are due to a "one time event" like a hospitalization for hip fracture surgery or big stroke, then perhaps they will not worsen and even improve with time and therapy. They may have a prognosis of months or they may have a prognosis of years.
If a person's need to have help with walking, bathing, dressing, and toileting are due to a progressing or incurable process such as dementia that is worsening or cancer that is spreading, then it is likely they will continue to lose strength, balance, energy, or stamina. They may have occasional "good days" when they can do more for themselves while continuously losing the ability to care for themselves. They may have a prognosis of months.
The faster and more extensive the changes, the more accurate the prognosis becomes.
When a person is preferring to sleep over interacting with family and working with physical therapy and when a person does not want to eat beyond sips and bites even with family bringing the straw or spoon up to their mouth, usually the person has a prognosis of days to limited weeks.
Being more aware of changes in what a person can do, hopefully, will result in more timely conversations about what if's, goals, values, love, gratitude, and forgiveness.
Hopefully this awareness would result in the person prioritizing how they want to spend their time as their strength and stamina changes (read Post 8: I Want the Best Care Possible For ME - Part 2 of 2), which may include working on a legacy project if they wished regardless of prognosis (read Post 12: Legacy Work and the Five Senses), naming a medical power of attorney [read Post 19: Bringing Up Medical Power of Attorney (MPOA) Doesn't Have to Be Awkward - A Six Step Guide], and discussing resuscitation wishes in a non hurried manner (read Post 5: CPR on TV versus CPR in Real Life - Three Ways They Differ).