Transcript Session 7 Dr. Brandt - Utah Hospice and Palliative Care Organization

Prognostication:
6 months or else!!!
Jamie Brant, MD
Adjunct Assistant Professor-University of Utah
AMG Senior Medical Group-Medical Director
Objectives
Define prognostication and understand
importance
Know common pathways to death
Review LCD’s (NHPCO guidelines) and
contrast with other prognostic tools
Review disease specific and non-disease specific
prognostication tools
Why is prognostication
important?
Helps with medical decision making
Allows end of life planning
Builds trust
Patients and families want to know
Do Patients Want to Know?
Those who did not have a prognosis conversation
were asked, do you want one?
Patients: 55% yes
40% no
5% I don’t know
Caregivers: 75% yes
23% no
2% I don’t know
Fried et al. JAGS 2003
Ahalt et al, JGIM
2011
“ Clinicians should…offer to discuss the
overall prognosis… for patients with a
life expectancy less than 10 years or at
least by…85 years of age”
NEJM
2011
What is Prognostication?
The Two parts:
1. Estimating the probability of an
individual developing a particular
outcome over a specific period of time
(prognosis).
2. Communicating the prognosis with the
patient and/or family.
If only it were this easy..
Challenges to Prognostication in
Older Adults
Younger patients with cancer: clearer trajectory
Older adults:
Absence of dominant terminal condition
age + functional + cognitive + multimorbidity
Low research Priority
Very little training
Population based studies are hard to individualize
Ways to prognosticate
Clinical prediction
LCD’s
Prognostic algorithms-most use symptoms, labs
and disease specific variables
Disease specific pattern of decline
Trajectory
Wise Providers Opinion
Shortcomings of Clinical Predictions
Tend to overestimate patient survival by a factor
of between 3 and 5.
Tend to be more accurate for very short-term
prognosis than long-term prognosis.
37% would not prognosticate even if asked
Influenced by relationships
The length of doctor patient relationships
increases the odds of making an erroneous
prediction.
Christakas, Annals on Int Med, 2001
Nurse Predictions
Minimum Data Set
Item J5c-less than 6 month prognosis (EOL)
Only 4% of admissions were considered EOL
Of the 4% of admissions designated EOL
50% died within a month
83% died within 6 months
Porock et al. BMC Research Notes 2010;3:200
LCD’s-NHPCO guidelines
Operation Restore Trust in 1996
Guidelines
Not intended to be public policy
Goal was to increase access to care but has limited access
Not Validated
Not accurate
Interpretation is different with different intermediaries
Fox et al, JAMA 1999: 282: 1638-1645 Schonwetter, AJHPM 2003
Prognostic Indices
Providers can use prognostic indices to lend
confidence to their judgments about prognosis
Prognostic indices provide an objective measure
to support clinical intuition
Combining clinical estimates with prognostic
indices results in more accurate estimates than
either alone.
Christakis & Iwashyna, Arch Intern Med 1998
Disease specific patterns
Short Period of Decline-20%
Solid organ failure-30%
Frailty/dementia-50%
Short Period of Decline
Sudden Death
Dependent on 0.69 ADL’s 1 year prior to death
Dependent on 1.22 ADL’s 1 month prior to
death
Highly functional prior to death
Looked at 7 ADL dependency over time
Lunney, JR, JAMA 2003, 289 (18) 2397, Patterns of Functional Decline
Malignancy
Relatively functional until 3 months prior to
death
Steady decline around 3 months prior
1 year prior to death-dependent with 0.77
ADL’s
1 month prior to death-dependent with 4.09
ADL’s
Lunney, JR, JAMA 2003, 289 (18) 2397, Patterns of Functional Decline
Solid Organ Failure
Solid Organ Failure (30%)
Stepwise decline with multiple exacerbations
Don’t return to baseline in between
Die during exacerbations
Fluctuations in functional status
1 year prior to death-1.22 ADL’s
3 month prior to death-3.66 ADL’s
Timeframe-2-5 years
Lunney, JR, JAMA 2003, 289 (18) 2397, Patterns of Functional Decline
Frailty/Dementia
Frailty (50%)
Multiple comorbidities
Extreme elderly
Early functional decline and slow rate of decline
1 year prior to death-2.92 ADL’s
1 month prior-5.84 ADL’s
Timeframe-6-8 years
Lunney, JR, JAMA 2003, 289 (18) 2397, Patterns of Functional Decline
Factors in Prognosis (frailty)
Trajectory!!
Comorbidities
Nutritional status
Change in dependence with ADL’s
Depression/Will to live
Gender
Hospitalizations/infections
Age
Cognitive Status
Non-disease specific prognostic
tools
Weight/BMI/MAC
Albumin
PPS
Karnofsky
Cognitive assessments-MMSE or MOCA
Functional status-ADL’s
Non-disease specific tools
Palliative Prognostic Score (PaP)-30 day
prediction
Prognostat-1 year prediction
E-prognosis-variable
Fast Fact # 124
Yourman L C. JAMA ; 307(2): 182-192
Mr. W
82 year old male with a history of congestive
heart failure (EF 60%) yet SOB at rest, severe
depression s/p ECT after his wife died 1 year
ago, CRI (GFR 15), DM (insulin dependent).
He has been to the ER 4 times in last 6 months
with 1 hospitalization. His only cardiac
medication is furosemide as he cannot tolerate
indicated medications due to hypotension and
hyperkalemia. He has become dependent w/ 5
ADL’s in last 6 months. Goals are comfort.
Would you….
A. Admit him to hospice, Cardiac LCD
B. Admit to hospice, Renal failure LCD
C. Admit to HH and cardiac rehab
D. Admit to hospice, using non-disease
specific decline in clinical status LCD with
contributing diagnosis’ being CHF, Renal
failure and diabetes
NHPCO
Cardiovascular Disease
NYHA class IV symptoms/angina at rest
Maximally treated with medications
EF less than 20% (not required but in support)
Treatment resistant arrhythmias, Hx of cardiac
arrest, Hx of cardio-embolic CVA, unexplained
syncope or HIV
Less than 50% accurate in predicting mortality
Unpredictable decline with frequent sudden death
Congestive Heart Failure
Biggest predictors of death
Age greater than 60
DMInsulin dependent-double hazard ratio (HR)
Non-insulin dependent 58% increase in HR
Hospitalization in last 6 months-73% increase HR.
EF-for every 5% decrease in EF-results in 13% increase in HR
Other-low diastolic BP, cardiomegaly, worsened NYHA class
http://www.heartfailurerisk.org/
Pocock, S J, et al. European Heart Journal. 2006(27): 65-75
Predicting mortality in patients with heart
failure: a pragmatic approach
Diabetes mellitus
Lower BP
Renal dysfunction
Poor QOL scores
Class IV heart failure (50%
annual mortality)
Ankle Edema
M L Bouvy, et al. Heart. June
2003; 89(6); 605-609
Lower BMI
Congestive Heart Failure
Systematic review of 16 studies-80,000 patients
GFR divided into normal (greater than 90 or creatinine less
than 1, creatinine 1-1.5 or greater than 1.5)
Mortality at 1 yr was 24% for normal, 38% for mild to
moderate and 54% for moderate to severe impairment.
For every 10 ml/min reduction in GFR, annual mortality
increased by 15%
Lassus J et al. Eur Heart J. 2007;28(15):1841
Seattle Heart Failure Model
Derived and validated in a broad HF
population
Includes general outpatients and advanced HF
patients.
Incorporates a wide range of readily available
clinical variables
1, 2 or 3 yrs survival rates
Labs/Biomarkers
BNP-greater than 240 despite optimal therapy
Hyponatremia
Low albumin
Anemia
Low cholesterol
Elevated Uric Acid
Cytokines-CRP etc
Cardiovascular Disease
Summary
Basic labs: Creatinine, Na, Anemia
Biomarkers: BNP, cystatin-C, CRP, troponin
Recent hospitalization for cardiac (3 fold increase)
Hypotension/tachycardia
EF less than 40%
Ventricular dysrhythmia
Comorbidities
Cachexia
Weisman-Fast Fact number 143 and Val-HeFT trial .
(2148)
Davis AJHPM 2005; 22: 211.
Biomarkers in heart failure. NEJM; 2010: 358
Mrs. G
72 yr old female with stage IV breast cancer
continued progression despite second line palliative
chemotherapy.
PPS/KPS 40
Dependent with 5 ADL’s
3+ edema
15 lb weight loss in the last 2 months
What is her prognosis?
A. Around 6 months
B. Around 3 months
C. Around 1 month
D. Less than 1 week
NHPCO
Cancer
PPS less than 70
Dependence on >/= 2 ADL’s
One of the following:
Distant metastasis at presentation
Progression despite therapy/declines therapy
Small cell lung cancer
Pancreatic cancer
Brain cancer
Oncology Terminology
Eastern Cooperative Oncology Group (ECOG)
Normal (0)-------------Dead (5)
3-limited self care/bed or chair >50% of waking hours
Karnofsky Scale
Normal (100)-------------------Dead (0)
50-considerable assistance with frequent medical care
Karnofsky <40 or ECOG 3-----median survival 3 months
PPS for Cancer-Fast Fact 125
Based on 3 studies
All were cancer patients
All were inpatient palliative unit or acute
inpatient hospital setting
PPS-V2
Poor prognostic indicators
Hypercalcemia
Malignant pleural/pericardial effusion
Carcinomitous meningitis
Brain/liver metastasis
Poor nutritional status
Edema
Dysphagia/anorexia
Malignancy specific
Palliative prognostic index
- PPS
-Edema
- Anorexia
- Dyspnea
-Oral intake
- 3 and 6 week survival
Mr. S
74 year old male with COPD (maximized Rx)
FEV1-40% (2 years ago)
PPS-50
Increasing LE edema
Worsening hypotension and hypoxia
SOB with eating/conversation
Clubbing
Respiratory failure 1 month ago-intubated x 6
days
Goals-get home from SNF and be independent
Would you admit to hospice?
Yes-under Lung disease LCD
Repeat PFT’s and if FEV1 is less than 30%,
admit to hospice
No-continue pulmonary rehab for the next
month to see how much he improves.
NHPCO
Pulmonary Disease
PPS less than 70 and dependence w/ ADL’s
All present
Dyspnea at rest
Poor response to bronchodilators
Decreased function
Increased emergency visit
FEV1 less than 30% (if available)
Decrease in FEV of 40ml/year (if available)
One present
Hypoxemia or hypercapnia
Supporting Documentation
Cor Pulmonale, weight loss, resting tachycardia
COPD-hospitalized patient
Ventilation required/hypercapnia
10% die in hospital
33% die within 6 months
43% die within 1 year
Previous ventilation
Prolonged ventilation (>3 days)
Higher APACHE score (severity)
Low albumin/hgb
Nevins. Chest; 2001: 1840-9 and Fast Fact #14
SUPPORT Study
Prognosis-30-40% 6 month mortality
Baseline PaCO2 >45
Cor Pulmonale
FEV1 < 0.75 liters
Respiratory failure in the last 6 months.
Poor prognostic indicators
Advanced age
Dyspnea at less than 50 feet
Unmarried
Depression
Functional decline
Comorbid illness
FEV 1 < 30%
Hansen-Flaschen. Resp Care. 2004: 49 (1); 90-97.
BODE Index
FEV 1
6 minute walk test
Dyspnea severity
BMI
Mrs. G
96 yr old female with Alzheimers dementia (FAST 6d)
and recent hospitalization for PNA
Weight down 10 lbs in last year (96 lbs)
Increase in wandering and agitation
Dependent with all ADL’s including eating
PPS 40
Two episodes of right middle lobe PNA in last year
Major changes over the last 6 months.
Goals are comfort
Would you admit to hospice?
A.
Yes, dementia as terminal dx using dementia
LCD.
B. Yes, dementia as terminal dx using nondisease specific decline LCD
C. Yes, under debility
D. No, follow her for another month to
determine direction and rehab potential
NHPCO
Non-disease specific decline
Recurrent infection (major)
Poor nutritional status-weight,, MAC, albumin
Dysphagia
Worsening symptoms (SOB, cough, n/v, diarrhea pain)
Worsening signs (hypotension, third-spacing, weakness,
change in consciousness)
Decline in PPS
Why does frailty matter?
High mortality rate within 6-12 months
High risk for falls/hip fracture
Outcomes for treatments may be less favorable
(ie: flu shot)
Frailty-5 markers
Weight Loss (greater than 10 lbs)
Fatigue (subjective report)
Slow walk speed (15 ft in 6-7 seconds)
Low activity level (less than 270kcal/week)
Weakness (grip strength)
Men less than 30 kg
Women less than 20 kg
Frailty
Weight loss of 5 percent in last year
Inability to rise from a chair five times without use of
arms, or
A "no" response to the question "Do you feel full of
energy?”
Ensrud KE, et al. Arch Intern Med. 2008;168(4):382.
Severely frail
Irreversible for severely frail older adults (4-5)
Low albumin or cholesterol=very high 6-12
month mortality
Likely, poor treatment response.
Mrs. S
96 year old female with alzheimer’s dementia in ALF
Incontinent b/b
Mostly parrots words back
Ambulation with walker, unsteady transfer
Dependent with bathing, dressing, toileting and meal
prep
Hospitalized 1 year ago with UTI/delirium
No changes over the last year.
10% weight loss 9 months ago but now stable.
Would you admit to hospice?
A. Yes, terminal diagnosis of dementia using dementia LCD
B. Yes, terminal diagnosis of dementia using non-disease
specific decline in clinical status LCD
C. No, watch for signs of decline.
NHPCO Guidelines
Dementia
PPS less than 70 and dependence with 2 +ADL’s
Fast Stage 7 or beyond
One of the following over the last year
Aspiration PNA
Pyelonephritis
Septicemia
Stage III or IV decubitus ulcers
Recurrent fever
10% weight loss over 6 months or low albumin
FAST scoring
6 D. urinary incontinence
6 E. fecal incontinence
7A. <6 intelligible words during conversation/day
7 B.-single intelligible word in an average day/conversation
7 C.-non-ambulatory
7 D.-unable to sit up
7 E. –loss of ability to smile
How accurate is FAST?
FAST 7-only 40% died in 6 months
Of the dementia patients that died, only 22%
had a FAST 7c or greater
Mortality Risk Index
Based on MDS –nursing home residents
Better predictor than FAST
Uses 12 variables and assigns points
Fast Fact #150
Mitchell. JAMA 2004; 291: 2734-2740
Summary Pearls
Prognostication is important so ASK!
General patterns of decline
Functional decline
Trajectory!!
Use your toolkit to support your clinical
judgment