Catholic Medical Quarterly Volume 75(2) May 2025
Commentary on “A review of the utility of prognostic tools in predicting 6-month mortality in cancer patients, conducted in the context of voluntary assisted dying”[1]
Fr Patrick Pullicino
Fr Pullicino is a retired Professor of
Neurology and a priest currently in Malta.
This paper reviewed 17 different prognostic tools to determine the specificity and sensitivity of predicting mortality within six months in a palliative care cohort of cancer patients in Victoria Australia. The conclusion of the authors was that there is no highly accurate method of determination of prognosis at 6 or 12 months. They tested 42 different prognostic groups and the most accurate tool was the Multidimensional Prognostic Index which found that 75.0% of patients with a high index (>0.66) died within 6 months, compared to 34.4% of patients with a low score (<0.33).
Firstly assisted dying is not moral and therefore using any tool however accurate to select patients “objectively” for this is also immoral.
Secondly, we instinctively know, predicting timeframe of death is impossible. These recent figures are similar to those from 20022 which found that a prediction in terminal cancer was only 80% accurate for death in 6 months. We know from many individual cases that prayer can bring about miraculous cures and predicting time of death has a fatalistic ethic about it that can be very demoralising to patients.
Death in medical conditions such as advanced heart failure, heart failure, pulmonary disease, HIV, liver disease, renal disease are less accurate than cancer being about 50% accurate for 6 month survival.
As the authors of this paper commented many of the tools used only functionality to predict survival, which are slanted towards an immoral “quality of life” type of determination. This also brings into question of how much bias was introduced by “palliative” care. In the UK end of life pathways shorten life predictably and studies of intracerebral haemorrhage patients have shown that active treatment in those with a poor prognosis improves outcome substantially. The fact that this study showed that prediction of shorter prognosis determination was significantly more accurate is counterintuitive and suggests that palliative care could have biased this finding.
In summary, I quote Tannenberger et al’s [2] conclusion: “Health care systems should avoid models for care with standards and budgets based on prognostic estimates and the medical community should avoid claim by disciplines of certain categories of patients defined by their prognoses”
References
1. Trevelyan L. et al. A review of the utility of prognostic tools in predicting 6-month mortality in cancer patients, conducted in the context of voluntary assisted dying. Internal Medicine Journal 2023;53:2180
2. Tannenberger S. et al. Planning palliative or terminal care: the dilemma of doctors’ prognoses in terminally ill cancer patients. Annals of Oncology 2002;13:1319-1320