PROGNISTICATION: SHARPENING THE CRYSTAL BALL

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 newly- diagnosed 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 1 st 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 1 st 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% 3-619% % 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 (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 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 yrs. Functional Status – relative risk of dying within 3 yrs. of starting dialysis is 1.44 for those w Karnofsky score 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 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 – and a good example of the tool in use: Heart failure – COPD – BODE calculator – ESRD – Charlson Comorbidity Index – indexwww.soapnote.org/elder-care/charlson-comorbidity- index or – - download your own versionwww.biomedcentral.com/ /4/94 Decompensated Liver Failure – MELD Score EPERC – End of Life/Palliative Education Resource Center – Medical College of Wisconsin – all things hospice and palliative care