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PROGNOSIS This is crucial for the legal process, but doctors may not naturally deal with the question of prognosis in exactly the way that lawyers and others require.
GIVING A PROGNOSIS IN CLINICAL PRACTICE often means giving general advice about whether a patient who has, for example, suffered an episode of depression is ready to go back to work or not.
Another example would be whether a patient who has had an episode of psychosis and has been an inpatient, will be able to return to his flat where he lives alone. Or whether, on the other hand, his ability to function independently is now impaired to the extent that he now needs to consider moving into some form of supported or warden-controlled accommodation.
In both these cases, the doctor will also be considering diagnosis and treatment simultaneously with prognosis. He may tend to view prognosis as something which "will come out in the wash"- a gradual process involving trial and error rather than a definitive endpoint.
GIVING A PROGNOSIS IN MEDICOLEGAL PRACTICE is very different.
Usually it will be a patient who is new to the doctor, who is seen on one occasion only. On the basis of the interview, documents and any other information such as special tests or video, the doctor has to try to predict the future course of the symptoms and function.
He has to express this in a reasoned way, taking into account various contingencies, such as for example, response to treatment.
This is likely to be new territory for most clinicians. Hence, as with effects upon function, doctors may benefit from guidance from those instructing them in order to deal with this aspect adequately.
GIVING A PROGNOSIS STARTS WITH:
THE CURRENT STATE
- the current effects of the health problems, physical and mental
- on the individualís ability to function in respect of
- personal,
- family,
- social
- occupational life
These points are a description of the current state of the individual, summarising the key points from the foregoing sections of the report.
THE CURRENT DIAGNOSIS
The prognosis then moves on to consider:
- the natural history of the health problems without treatment
- discuss the likely effects of treatment on the symptoms
- and on functional abilities.
These points can be guided by published research studies or textbook material. However, research studies tend to be "ivory tower", and cannot necessarily be extrapolated directly into the medicolegal setting.
THE FINAL PROGNOSIS summarises the above factors, and also must take into account: - the individual's overall pre-accident adjustment
- personality factors
- and must consider perpetuating factors.
POSITIVE FACTORS IN PROGNOSIS Although the following points might seem to come from "the University of the Bleeding Obvious," they are nevertheless amongst the most powerful determinants of outcome:
- young age,
- good pre-illness adjustment regarding work, family and social life
- good previous health
- early diagnosis of the health conditions
- the health problems are mild
- effective treatment recieved
- lack of complicating factors (for example, alcohol misuse)
- supportive family and employer
These are associated with favourable prognosis; the converse of course applies to each of these factors.
ADVERSE FACTORS IN PROGNOSIS The outlook tends to be poorer:
- in older claimants
- with protracted and more severe symptoms
- previous personal, health financial, employment, family or social problems
There is a tendency for claims and disability to come from areas of socio-economic deprivation more frequently than would be expected by chance alone.
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