Transcript End of Life Care: The Jewish Way

Predicting Prognosis:
Guidelines for
End-of-Life Decisions
Objectives
• Identify two general clinical indicators of a lifelimiting prognosis
• Define two disease-specific prognostic
indicators
• Verbalize trajectory of decline within diseases
which demonstrate hospice appropriateness
• Discuss case vignettes for ongoing
assessment of prognosis and documentation
specific to decline in function within diseases
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Medicare Hospice Benefit
• Terminal Illness: “A medical prognosis (of a)
life expectancy of six months or less if the
illness runs its normal course.”
• Certified by two physicians: attending and
hospice medical director
• Recertification requirement includes
documented assessment of prognosis of six
months or less and demonstrates declining
condition
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CLINICAL JUDGMENTS
• Specific criteria represent pieces of
information that should be evaluated in
the context of a patient’s clinical condition
and clinical course at the time of
assessment
• This information should be combined with
other clinical and psychosocial information
• Clinical judgment is based on the needs of
the specific patient
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General Guidelines
“Observations by physicians and others
in hospice and palliative care observed
that patients who are terminally ill,
regardless of the primary diagnosis,
had convergence of symptoms and
treatment approaches as the time of
death became closer.”
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is
Needed. Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common
Problems in End-of-Life Care. New York, McGraw Hill, 2001.
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Determining Prognosis
Clinical Progression of Disease
• Multiple hospitalizations, ED visits or increased
use of other healthcare services
• Serial physician assessments, laboratory or
diagnostic studies consistent with disease
progression
• Changes in MDS in LTC facilities
• Co-morbidities
• Progressive deterioration
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed. Chapter 1
in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of-Life Care. New
6
York, McGraw Hill, 2001.
Determining Prognosis
Changes in Functional Status
• Cancer Patients
– PPS < 50 or ECOG > 3
– PPS < 60 or ECOG > 2 with symptoms
– Decline in PPS of at least 20 units in 2-3 months
• Non-Cancer Patients
– Dependence in at least 3/6 Activities of Daily
Living
– PPS < 50
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of7
Life Care. New York, McGraw Hill, 2001.
Palliative Performance Scale
%
Ambulation
Activity/ Evidence Self
of Disease
Care
Intake
Conscious
Level
100
Full
Normal activity no
evidence of disease
Full
Normal
Full
90
Full
Normal activity some
evidence of disease
Full
Normal
Full
80
Full
Normal activity with
effort some evidence
of disease
Full
Normal
or
reduced
Full
70
Reduced
Unable normal
job/work some
evidence of disease
Full
Normal
or
reduced
Full
60
Reduced
Unable hobby/house
work significant
disease
Occasional
assistance
necessary
Normal
or
reduced
Full or
confusion
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Palliative Performance Scale
Ambu% lation
Activity/Evidence
of Disease
Self-Care Intake
50 Mainly
sit/lie
Unable to do any
work, extensive
disease
Much
assistance
required
Normal or Full or
reduced
confusion
40 Mainly
in bed
Unable to do any
work, extensive
disease
Mainly
assistance
Normal or Full or
reduced
drowsy or
confusion
30 Totally
bed
bound
Unable to do any
work, extensive
disease
Total care
Reduced
Full or
drowsy or
confusion
20 Totally
bed
bound
Unable to do any
work, extensive
disease
Total care
Minimal
sips
Full or
drowsy or
confusion
10 Totally
bed
bound
Unable to do any
work, extensive
disease
Total care
Mouth
care only
Drowsy or
coma
0
Death
Conscious
Level
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Index of Independence in Activities
of Daily Living
Six Functions:
Index Levels:
* Bathing
A. Independent in feeding, continence, transferring, going
to toilet, dressing, and bathing
* Dressing
B. Independent in all but one of these functions.
* Going to Toilet
C. Independent in all but bathing and one additional
function.
*Transfer
D. Independent in all but bathing, dressing and one
additional function.
* Continence
E. Independent in all but bathing, dressing, going to toilet,
and one additional function.
* Feeding
F. Independent in all but bathing, dressing, going to toilet,
transferring, and one additional function.
G. Dependent in all six functions
Other:Dependent in at least two functions, but not
classifiable as C,D,E or F.
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Adjusted Proportion of People with
Trouble Getting in and out of Bed or Chair
0.7
Proportion
0.6
0.5
0.4
0.3
0.2
0.1
0
12
11
10
9
8
7
6
5
4
3
2
1
0
Month Before Death
Cancer
CVA
COPD
Diabetes
CHF
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Determining Prognosis
Unintentional Weight Loss
• > 10% of normal body weight
• Body Mass Index (BMI) < 22 kg/m2
Of Note: For ongoing determination of
wasting, documentation of Mid-arm Muscle
(MMA) is a significant indicator of decline
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed. Chapter
1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of-Life Care.
12
New York, McGraw Hill, 2001.
Determining Prognosis
Intangible Factors
• Patient’s personal goals and approach to his
or her disease
• Burden of investigation and treatment vs.
potential gains for the patient
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed. Chapter
1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of-Life Care.
New York, McGraw Hill, 2001.
13
Determining Prognosis
Cancer Diagnoses
• Stage IV — presence of metastases
• Natural history of disease
• Sensitivity of the disease to
anti-neoplastic therapy
• Prior treatment history where indicated
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of-Life Care.
New York, McGraw Hill, 2001.
14
Determining Prognosis
End-stage Cardiac Disease
• Symptomatic at rest or with minimal exertion
– Heart Failure: Ejection Fraction < 20%
– Dyspnea or chest pain at rest or minimal exertion
(NYHA class IV)
• Optimal medical therapy or inability to
tolerate optimal therapy
• Not a surgical candidate
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-ofLife Care. New York, McGraw Hill, 2001.
15
The Stages of Heart Failure –
NYHA Classification
In order to determine the best course of therapy,
physicians often assess the stage of heart failure
according to the New York Heart Association
(NYHA) functional classification system. This
system relates symptoms to everyday activities
and the patient's quality of life.
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Class/Patient Symptoms
• Class I (Mild)No limitation of physical activity.
Ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnea
• Class II (Mild)Slight limitation of physical activity.
Comfortable at rest, but ordinary physical activity
results in fatigue, palpitation, or dyspnea.
• Class III (Moderate)Marked limitation of physical
activity. Comfortable at rest, but less than ordinary
activity causes fatigue, palpitation, or dyspnea.
• Class IV (Severe)Unable to carry out any physical
activity without discomfort. Symptoms of cardiac
insufficiency at rest. If any physical activity is
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undertaken, discomfort is increased.
End-stage Cardiac Disease
“There is a failure to recognize that end-stage
heart failure patients frequently come in and
out of the hospital over and over again and
suffer a lot with really no impact on their
ultimate survival”
Mariell Jessup, MD, FACC, medical director of the heart failure and cardiac transplantation
program and professor of medicine, Univ of PA 9/05/05
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End-stage Cardiac Disease
• ACC/AHA Practice Guidelines (2005)
recommendations
– Stage D Refractory Heart failure (HF) requiring
specialized interventions
• Recurrently hospitalized or
• Cannot be safely discharged from the hospital without
specialized interventions
– Marked refractory symptoms at rest
• Shortness of breath
• Fatigue
• Reduced exercise tolerance
– Compassionate end of life care/hospice
– Extraordinary measures
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End-stage Cardiac Disease
• Co-morbid conditions associated with poor
prognosis
– Symptomatic arrhythmias resistant to
antiarrhythmic therapy
– History of cardiac arrest and resuscitation
– History of syncope, regardless of etiology
– Cardiogenic brain embolism
– Concomitant HIV disease
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-ofLife Care. New York, McGraw Hill, 2001.
20
End-stage Pulmonary Disease
• In advanced disease the clinical course of
patients usually consists of periods of
relatively stable disease punctuated by
episodic acute decompensation
• In disease progression:
– Acute episodes become more frequent
– Periods of stability become the exception rather
than the rule
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End-stage Pulmonary Disease
• Progression in disease manifested by:
– Multiple hospitalizations, ED visits or doctor’s
office visits
– Body weight ≤ 90% of ideal body weight
or ≥ 10% loss of weight
– Resting tachycardia > 100/min
– Abnormal blood gases, if available
• Po2 ≤ 55mm Hg or O2 saturation ≤ 88%
• Pco2 ≥ 50mm Hg
– Continuous oxygen therapy
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Determining Prognosis
End-stage Pulmonary Disease
• Dyspnea at rest or with minimal exertion
• Dyspnea poorly responsive to
bronchodilators
– FEV-1 < 30% predicted, post-bronchodilator
• Cor pulmonare
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-ofLife Care. New York, McGraw Hill, 2001.
23
Determining Prognosis
End-stage Dementias
• FAST Stage 7
– Inability to ambulate without assistance
– Inability to speak or communicate meaningfully
• Co-morbid conditions
–
–
–
–
Aspiration pneumonia or sepsis
Decubitus ulcers – Stage III or IV
Altered nutritional status
Fever recurrent after antibiotics
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in
End-of-Life Care. New York, McGraw Hill, 2001.
24
End-stage Dementias
• Altered nutritional status as manifested by:
– Difficulty swallowing or refusal to eat such that
sufficient fluid or caloric intake cannot be
maintained and the patient refuses artificial
nutritional support
OR
– Patient is receiving artificial nutritional support (NG
or G tube or parenteral hyperalimentation), there
must be evidence of impaired nutritional status as
defined in the General Guidelines (≥ 10% loss of
body weight)
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of25
Life Care. New York, McGraw Hill, 2001.
Determining Prognosis
Acute Cerebrovascular Disease & Coma
• One of the following conditions for at least 3
days durations:
–
–
–
–
Coma
Persistent Vegetative State
Severe obtundation accompanied by myoclunus
Postanoxic stroke
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J:
20 Common Problems in End-of-Life Care. New York, McGraw Hill, 2001
26
.
Acute Cerebrovascular Disease
& Coma
• Other factors associated with high risk of
mortality after 3 days (Hamel et al, 1995):
–
–
–
–
–
Abnormal brainstem response
Absent verbal response
Absent withdrawal response to pain
Serum creatinine ≥ 1.5mg/dl
Age ≥ 70 years
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is
Needed. Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems
in End-of-Life Care. New York, McGraw Hill, 2001.
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Chronic Cerebrovascular Disease,
Coma & Persistent Vegetative State (PVS)
• Post-Stroke or multi-infarct dementia
consistent with FAST 7, if the patient is not
comatose or in PVS
• One or more of the following co-morbid
conditions in the past 3-6 months:
– Aspiration pneumonia
– Pyelonephritis or upper urinary tract infection
– Septicemia
– Decubitus ulcers, usually multiple stage III – IV
– Fever, recurrent after antibiotics
– Altered nutritional status as noted for dementia
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
28
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of-Life
Care. New York, McGraw Hill, 2001.
Altered Nutritional Status
• Difficulty swallowing or refusal to eat such that
sufficient fluid or caloric intake cannot be
maintained and the patient refuses artificial
nutritional support
OR
• Patient is receiving artificial nutritional support
(NG or G tube or parenteral hyperalimentation), there
must be evidence of impaired nutritional status
as defined in the General Guidelines
(≥ 10% loss of body weight)
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
29
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-of-Life
Care. New York, McGraw Hill, 2001.
Determining Prognosis
• Amyotrophic Lateral Sclerosis (ALS) and other
forms of Motor Neuron Disease
– Rapid progression of ALS
• Development of severe neurological disability over a 12month period
– Independent ambulation to wheelchair or
bed bound
– Normal to barely intelligible or unintelligible speech
– Normal to blenderized diet
– Independence in most ADLs to needing major assist in
all ADLs
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ALS and Other Forms of Motor
Neuron Disease
• Critically impaired ventilatory capacity
– Vital capacity < 30% predicted
– Significant dyspnea / Oxygen needed at rest
– Refusal by patient of intubation, tracheostomy, other
forms of mechanical vent support
– Critical nutritional impairment
• Co-morbid conditions
–
–
–
–
–
Aspiration pneumonia
Pyelonephritis or upper urinary tract infection
Septicemia
Decubitus ulcers, usually multiple stage III–IV
Fever, recurrent after antibiotics
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Determining Prognosis
End-Stage Renal Disease
• General Criteria
– Meet criteria for dialysis and/or renal transplant
and refuse
– Refuse to continue dialysis
• Laboratory Criteria
– Creatinine clearance < 10 mL/min
(< 15 mL/min with diabetes)
– Serum creatinine > 8 mg/dl
(> 6.0mg/dL with diabetes)
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
32
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-ofLife Care. New York, McGraw Hill, 2001.
End-Stage Renal Disease
• Signs/symptoms of Progressive Uremia
–
–
–
–
–
–
Confusion and obtundation
Intractable nausea and emesis
Generalized pruritis
Restlessness
Oliguria: urine output < 400mL/24 hrs
Intractable hyperkalemia: serum potassium
> 7.0, not responsive to medical management
– Pericarditis
– Intractable fluid overload
– Hepatorenal syndrome
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Acute Renal Failure
Co-Morbid illness associated with poor prognosis
• Mechanical ventilation
• Chronic lung disease
• Advanced liver
disease
• Immunosuppression /
AIDS
• Cachexia
• Age > 75 years
• Gastrointestinal
bleeding
• Malignancy
• Advanced cardiac
disease
• Sepsis
• Serum albumin
<3/5g/dL
• Platelet count
<25,000
• Disseminated
intravascular
coagulation (DIC)34
Determining Prognosis
End-Stage Liver Disease
• Progressive symptoms not responsive to
medical management or patient noncompliance,
including:
– Ascites, refractory to sodium restriction and diuretics,
especially with associated spontaneous bacterial
peritonitis
– Hepatic encephalopathy refractory to protein
restriction and lactulose or neomycin
– Recurrent variceal bleed despite therapeutic
interventions
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– Hepatorenal syndrome
End-Stage Liver Disease
• Lab indicators
– Protime ≥ 5 seconds more than control
– Serum albumin ≤ 2.5 g/dL
• Other factors
– Progressive malnutrition
– Muscle wasting with reduced strength and
endurance
– Continued active ethanol intake
(> 80 g ethanol per day)
– Hepatocellular carcinoma
– HbsAg Positive
Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.
36
Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-ofLife Care. New York, McGraw Hill, 2001.
Determining Prognosis
End-Stage AIDS
• CD4+ count < 25 cells/μL in periods free of
acute illness
• HIV RNA (viral load) > 100,000 copies on a
persistent basis
• HIV RNA (viral load) < 100,000 copies in the
presence of:
– Refusal to receive antiretroviral or prophylactic
medications
– Declining functional status
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End-Stage AIDS
Other factors associated with poor prognosis
–
–
–
–
Chronic persistent diarrhea for 1 year
Persistent serum albumin < 2.5g/dL
Age > 50 years
Decision to forego antiretroviral therapy,
chemotherapy and prophylactic drug therapy
related to HIV
– Congestive heart failure, symptomatic at rest
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Determining Prognosis
Adult Failure to Thrive and Debility
Unspecified
• General Criteria
– Declining Functional Status
– Unintentional Weight Loss
• > 10% ideal body weight
– Body Mass Index (BMI) < 22 kg/m2
Of Note: Mid-arm muscle measurement (MMA) very
important for ongoing documentation of decline
• Multiple illnesses (Co-morbidities) with no
single illness or diagnosis itself being terminal39
Evaluation of Therapy and
Treatments for Continued
Appropriateness
• Case Vignette
– Cardiac patient with no oxygen in the home
Pick one from your practice setting for our
discussion
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