BMJ  2005;330 (19 March), doi:10.1136/bmj.330.7492.0-h

Editor's choice

Charcot would have approved

As he walked the wards of the Salpetriere Hospital in 19th century Paris, Charcot allegedly gave only two prognoses, solemnly pronouncing at the end of each bed "Il va mourir," or "Il va mourir aujourd'hui." A bleak message definitely, and bluntly delivered, but there is something enviable in its certainty and simplicity. Of course he was short of effective treatments, and accurate prognosis was often the only useful thing medicine could offer, so the art of prognosis was highly valued and was a big part of the medical curriculum.

Today, while death remains stubbornly inevitable, modern medicine can and does postpone it. But has this success made us forget the importance of prognosis? Murray and colleagues think it has (p 611), especially in people with progressive chronic disease. Being busy managing and monitoring a long term illness can prevent (or perhaps protect) us from seeing that the patient is in irreversible decline, and so we rob them of the chance to plan for a good death. To avoid such "prognostic paralysis" and identify patients who could benefit from holistic palliative care, Murray advises asking the simple question, "Would I be surprised if my patient were to die in the next 12 months?"

Thanks to modern medicine and advances in public health we are living longer. But we are also living longer with illness. As this theme issue highlights, chronic diseases now affect six out of ten adults and one in five to six children in the UK (p 657) and by 2020 will account for four fifths of the global burden of disease. Managing chronic disease presents enormous challenges to health systems and individuals. Several of this week's articles tell us that to meet these challenges we need (as well as more money and better systems) new skills and training (pp 633, 637, 644, 651) to help us shift the emphasis away from acute hospital medicine to coordinated, collaborative, patient centred care (p 662). As Campbell and McCauley point out (p 667), unless doctors are trained to understand chronic illness, their unrealistic expectations may foster negative attitudes and the perception that some patients are hard to treat when they fail to respond.

Finding easy and accurate ways to predict response is key to informing patients and planning treatment. So it's good news from Doust and colleagues in their systematic review (p 625) that a simple blood test for B-type natriuretic peptide (BNP) strongly predicts the risk of death from heart failure, both in people with and without symptoms. Clinical assessment of heart failure is notoriously difficult, as is identifying those patients most likely to benefit from treatment. BNP turns out to be better at this than traditional prognostic indicators such as New York Heart Association class, serum creatinine, and possibly even left ventricular ejection fraction. Charcot would have approved.

Fiona Godlee, editor

(fgodlee{at}bmj.com)

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