Communicating prognostic uncertainties in advanced multimorbidity: a multimethod qualitative study to co-design practice recommendations

Abstract

Purpose: Older adults with advanced multimorbidity face an uncertain future due to their unpredictable illness trajectory. Communication of such uncertainty is a core task in healthcare, but there is a limited evidence base to support communication of prognostic uncertainty in multimorbidity. We aimed to co-design clinical practice recommendations for communication of prognostic uncertainty in advanced multimorbidity, based on the lived experience and expertise of patients, carers and healthcare professionals. Methods: Multi-method qualitative co-design study. In phase one, older adults with advanced multimorbidity, their informal carers, and health professionals participated in interviews and focus groups exploring experiences of uncertainty communication. Transcripts were analysed thematically. In phase two, attendees at two stakeholder events provided feedback on the findings and iteratively developed practice recommendations. Results: Fifteen older adults (median age 80, range 70-89), three informal carers, and 17 health professionals provided qualitative data. We then held workshops with 56 stakeholders. Participants considered that a personalised approach supported discussions of prognostic uncertainty; trusting care relationships, and regard for timing and preparation of all parties were needed. Participants agreed that discussions of uncertainty should proceed based on open and honest discussion within negotiated limits. Clinicians should signpost support and undertake parallel planning for the range of future possibilities to outline the boundaries of uncertainty. Conclusion: This study has developed recommendations for communication of prognostic uncertainty in older people with advanced multimorbidity, to support parallel planning for an unpredictable future. Implementing these recommendations. may reduce negative impacts of uncertainty and improve care experience.