Transcript PROGNISTICATION:

PRESENTED BY:
David L. Sharp, M.D.
Grand Rapids Medical
Education Partners
HOW’S YOUR CRYSTAL BALL WORKING?
MOST PHYSICIANS TEND TO OVER-ESTIMATE
REMAINING TIME FOR PATIENTS
2000 study by Nicholas Christakis, M.D.
• 343 physicians provided survival estimates for 468
terminally ill patients admitted to hospice service
• only 20% were accurate (defined as within 33% of actual
survival
• over-estimated by a factor of 5.3
• more experienced clinicians slightly more accurate
“The Conspiracy of Hope”
DO YOU KNOW WHAT YOUR KID IS DRINKING?
PROGNOSTICS
An engineering discipline focused on predicting
the future condition or estimating remaining
useful life of a component and/or a system of
components
Isn’t that what we’d like to do?
WHY IS IT SO HARD TO BE ACCURATE?
Imponderables
caregiver issues
environment
psychosocial aspects – truly, the Wild Card
spiritual - presence or lack of belief system
Variables
disease process
proper treatment
hospice support itself
RESERVE CAPACITY – TRAJECTORY OF DECLINE
Immune function
Neuroendocrinology
Cardiovascular factors
Stress response variables
BUT – WE DON’T STUDY THESE ONCE PATIENT IS IN HOSPICE
RULES OF THUMB 1
• How do you spend your day?
• How much time do you spend in a chair or lying down?
if >50% (and especially if increasing) – prognosis is
less than 3 months
further decrease in time left if increasing physical
symptoms, especially dyspnea, weight loss and
declining functional ability
PARADOX OF PAIN CONTROL
Pharmacological pain control can both:
• lengthen and improve survival time
• facilitate transition to actively dying stages
RULES OF THUMB 2 - CANCER
malignant hypercalcemia – 8 weeks (except newlydiagnosed breast cancer or myeloma)
malignant pericardial effusion – 8 weeks
carcinomatous meningitis – 8 – 12 weeks
multiple brain metastases – 1-2 months w/o radiation,
3-6 months w radiation
malignant ascites/pleural effusion/bowel obstruction <6 months
RULES OF THUMB 3 - CANCER
Patients with solid tumors typically lose 70% of their
functional ability in the last three months of life
Measured by:
Karnofsky Index
Eastern Cooperative Oncology Group (ECOG) Scale
Palliative Performance Scale (v. 2)
Palliative Prognostic Score
(see Handouts)
NON-PHYSICAL SURVIVAL INFLUENCES
more impact in non-cancer diagnoses than cancer diagnoses
more influence in remote than imminent circumstances
• “Will to Live” – major factor
• “giving up” – how long do you “fight” illness & death
• patient-perceived quality of life
• “having something to look forward to”
• anger / forgiveness
• the “reserved” good-bye – resolution of issues
MORE NON-PHYSICAL SURVIVAL INFLUENCES
Quality of life – control and choices
Stress level
Social support (loneliness is a killer)
Caregiver traits – attitude & experience – hostile? –
withholding? – inept? – handicapped?
Milieu of care
Medical literacy
THE HOSPICE CONFOUNDER
REDUCING THE BURDEN OF ILLNESS
consequences of chronic illness persist and
accumulate over several years
activities of daily living are typically reduced
results in “weariness with life”
social, psychological and rehabilitative interventions
“tilt the balance” toward protracted survival
results in positive effect on Will to Live
DISEASE-BASED SURVIVAL INFLUENCES
Cancer – almost linear degradation of systems – more
predictable
Non-cancer – (dementia, cerebrovascular disease) –
more erratic, with plateaus of stability
Cardiac – do not appear particularly ill, and yet die
suddenly and unpredictably
PROGNOSIS IN CRITICALLY ILL ADULTS
Acute Physiologic and Chronic Health Evaluation (APACHE IV) – based
on worst values during ICU Day 1, and updated
Mortality Probability Model (MPM III) – data during 1st hour of ICU
admission
APACHE IV and MPM III require computer-based software and (for
APACHE) laboratory data
Simplified Acute Physiology Score (SAPS III) – data during 1st hr. in ICU
– requires downloadable software
Scores are highly correlated with percentage mortality rates
Can help guide families and medical staff with EOL decision-making
DISCUSSING PROGNOSIS
PREPARATION - confirm that the patient/family are ready
to hear prognostic information
CONTENT – present information as a range – hours to
days, days to weeks, etc.
PATIENT’S RESPONSE – allow silence, respond to
emotion (have tissues nearby)
CLOSE – use prognostic information as a starting point
for discussing EOL goals
WHAT’S YOUR VIEWPOINT?
DEMENTIA
Qualifying for hospice services – should be in the 7-range:
Functional Assessment Staging
Stage 7
A. 6 words – speech limited to 6 or fewer words in use
B. 1 word – speech limited to one word during course of
interview
C. Unable to sit up
D. Unable to smile
E. Unable to hold head up
DEMENTIA 2
KATZ INDEX OF ACTIVITES OF DAILY LIVING:
A. unable to ambulate without assistance
B. unable to dress w/o assistance
C. unable to bathe w/o assistance
D. unable to eat w/o assistance
E. urinary or fecal incontinence, intermittent or constant
F. no meaningful verbal communication, stereotypical phrases
only, or ability to speak is limited to 6 or fewer intelligible words
DEMENTIA 3
Flacker Kiely Risk Assessment Tool (has largely replaced the
Mortality Risk Index Score of Mitchell) - (see handout)
If total score is: one-year mortality risk is:
0-2
7%
3-6
19%
7-10
50%
11+
86%
So…. We should be concentrating our hospice attentions to those
with scores of at least 7 or more (also explains why dementia
patients “linger so long”)
HEART FAILURE
New York Heart Association (NYHA) Classification and predicted
mortality:
Class II (mild symptoms) – 5-10% one-year mortality
Class III (moderate symptoms) – 10-15% one-year mortality
Class IV (severe symptoms) – 30-40% one-year mortality
NONETHELESS: unpredictable disease trajectory with high (25-50%)
incidence of sudden death
Seattle Heart Failure Model – see Handout for sources
HEART FAILURE 2 – SHORTER PROGNOSIS IF:
Recent cardiac hospitalization triples one-year mortality
Concurrent renal failure (elevated BUN and/or creatinine)
Systolic BP <100 or pulse >100 (each doubles one-year mortality)
Decreased ejection fraction (linear below 45%)
Treatment-resistant ventricular dysrhythmias
Anemia (each 1 gm/dl reduction associated w 16% increase in 1-yr mortality)
Hyponatremia
Cachexia
Reduced functional capacity
Co-morbidities: DM, depression, COPD, cirrhosis, cerebrovascular dz, Ca, HIV
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Using current guidelines, 50% of those qualifying for hospice still
alive @ 6 months
Comorbidities contributing to increased mortality risk:
heart disease with CHF
mechanical ventilation >48 hrs.
failed extubation
low hemoglobin and/or albumin
FLIP-SIDE – THERE IS A 50% MORTALITY FOR THOSE MEETING
CRITERIA FOR HOSPICE ADMISSION
END-STAGE CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
BODE SCALE (see Handout)
B ody Mass Index
O bstruction (FEV-1 percent of predicted)
D yspnea scale (0 – none to 4 – dyspnea dressing/undressing)
E xercise capacity – distance walked in 6 minutes, in meters
0-2 points on BODE Scale correlates to 2% one-year mortality
7-10 points correlates to 80% 52-month mortality
END-STAGE RENAL DISEASE
Age – over 18 – increase 3-4% in annual mortality, compared to
general population (1- and 2-yr mortality reaches 39 and 61% by
age 80-84 yrs.
Functional Status – relative risk of dying within 3 yrs. of starting
dialysis is 1.44 for those w Karnofsky score <70 compared with
those >70
Albumin
>3.5 gm/dl – 86 and 76% one- and two-year survival rates
<3.5 gm/dl – 50 and 17% one- and two-year survival rates
Best prognostic tool – age-modified Charlson Comorbidity Index
(CCI) – see References
PATIENTS RECEIVING DIALYSIS
Dialysis stopped when:
a) no longer substantially prolonging life, but only postponing
death – comorbidities of cancer, sepsis, multi-organ failure, etc.
b) burdens of dialysis & its complications outweigh life-prolonging
benefits (progressive frailty, severe cognitive failure, etc.)
Demographics – most commonly older age, white race, longer
duration of dialysis, higher educational level, living alone, severe
pain, significant co-morbidities
Survival after cessation ranged from 4 to 21 days, with mean of 8.5
plus/minus 4.8 days (French study, 2004, and others)
DECOMPENSATED CHRONIC LIVER FAILURE
Prognostic variables
hepato-renal syndrome
type 1 – rapid and severe RF – 8-10 weeks survival w or
w/o Rx
type 2 – less severe (Cr 1.5-2 mg/dl) – median survival 6
months
older age
concomitant hepatocellular carcinoma
MELD (Model for End-stage Liver Disease Score has supplanted the
CTP (Child’s-Turcotte-Pugh) Score (see References)
YOU THINK YOU’RE PARANOID?
PUTTING IT ALL TOGETHER….
Please refer to Handout:
“Ten Steps to Better Prognostication”
WOULD YOU LIKE ANOTHER OPINION?
REFERENCES AND WEB-BASED MODELS
Dementia – Flacker Kiely Assessment Tool –
http://www.uchsc.edu/palliativecare/flacker.php
and a good example of the tool in use:
http://www.chfwcny.org/Tools/BroadCaster/Upload/Project1127/Docs/CAP.Outcomes
.pdf
Heart failure – http://seattleheartfailuremodel.org
COPD – BODE calculator – www.qxmd.com./calculate-online/respirology/bode-index
ESRD – Charlson Comorbidity Index – www.soapnote.org/elder-care/charlson-comorbidityindex
or – www.biomedcentral.com/1471-2407/4/94 - download your own version
Decompensated Liver Failure – MELD Score
http://www.unos.org/resources/meldPeldCalculator.asp
EPERC – End of Life/Palliative Education Resource Center – Medical College of Wisconsin
– all things hospice and palliative care