PROGNISTICATION:

1. PROGNISTICATION: Sharpening the crystal ball

2. Presented by: • David L. Sharp, M.D. • Grand Rapids Medical • Education Partners

3. How’s your crystal ball working?

4. 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”

5. Do you know what your kid is drinking?

6. 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?

7. 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

8. Reserve capacity – TRAJECTORY OF DECLINE • Immune function • Neuroendocrinology • Cardiovascular factors • Stress response variables • BUT – WE DON’T STUDY THESE ONCE PATIENT IS IN HOSPICE

9. 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

10. Paradox of pain control • Pharmacological pain control can both: • lengthen and improve survival time • facilitate transition to actively dying stages

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. What’s Your viewpoint?

20. 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

21. 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

22. 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”)

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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)

29. 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)

30. You think You’re paranoid?

31. Putting it all together…. • Please refer to Handout: • “Ten Steps to Better Prognostication”

32. Would you like another opinion?

33. 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-comorbidity-index • 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