predicting prognosis: guidelines for end-of-life decisions

Predicting Prognosis: Guidelines for

End-of-Life Decisions

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Objectives

• Identify two general clinical indicators of a life-limiting 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 York, McGraw

Hill, 2001.

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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-of-Life Care. New York, McGraw Hill, 2001.

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Palliative Performance Scale

%Ambu-lation

Activity/ Evidence of Disease

SelfCare Intake

ConsciousLevel

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

ConsciousLevel

50 Mainly sit/lie

Unable to do any work, extensive disease

Muchassistance required

Normal or reduced

Full or confusion

40 Mainly in bed


Mainly assistance

Normal or reduced

Full or drowsy or confusion

30 Totallybed bound


Total care Reduced Full or drowsy or confusion

20 Totally bed bound


Total care Minimal sips

Full or drowsy or confusion

10 Totallybed bound


Total care Mouthcare only

Drowsy or coma

0 Death

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Index of Independence in Activities of Daily Living

Six Functions: Index Levels:

* BathingA. Independent in feeding, continence, transferring, going

to toilet, dressing, and bathing

* Dressing B. Independent in all but one of these functions.

* Going to ToiletC. Independent in all but bathing and one additional

function.

*TransferD. Independent in all but bathing, dressing and one

additional function.

* ContinenceE. Independent in all but bathing, dressing, going to toilet,

and one additional function.

* FeedingF. 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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0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

12 11 10 9 8 7 6 5 4 3 2 1 0

Month Before Death

Prop

ortio

n

Cancer CVA COPD Diabetes CHF

Adjusted Proportion of People with Trouble Getting in and out of Bed or

Chair

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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. New York, McGraw Hill, 2001.

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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.

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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.

15


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-of-

Life Care. New York, McGraw Hill, 2001.

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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 undertaken, discomfort is increased.

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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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• 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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• 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-

of-Life Care. New York, McGraw Hill, 2001.

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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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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-of-Life

Care. New York, McGraw Hill, 2001.

24


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.

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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)



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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.

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

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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



28Kinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.


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

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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)



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• Amyotrophic Lateral Sclerosis (ALS) and other forms of Motor Neuron Disease– Rapid progression of ALS

• Development of severe neurological disability over a 12-month 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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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. Chapter 1 in: Kinzbrunner BM, Weinreb NJ, Policzer J: 20 Common Problems in End-

of-Life Care. New York, McGraw Hill, 2001.

33

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 FailureCo-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)

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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

– Hepatorenal syndrome

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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 PositiveKinzbrunner BM: Predicting Prognosis: How to Decide when End-of-Life Care is Needed.


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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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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 terminal

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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

predicting prognosis: guidelines for end-of-life decisions

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