Predicting Prognosis Guidelines for End-of-Life Decisions Objectives

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 2

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 3

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 4

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, Mc. Graw Hill, 2001. 5

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, Mc. Graw 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-of 7 Life Care. New York, Mc. Graw 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 Full evidence of disease Normal Full 80 Full Normal activity with Full effort some evidence of disease Normal or reduced Full 70 Reduced Unable normal job/work some evidence of disease Normal or reduced Full 60 Reduced Unable hobby/house Occasional Normal work significant assistance or disease necessary reduced Full or confusion 8

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 9

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. 10

Adjusted Proportion of People with Trouble Getting in and out of Bed or Chair 11

Determining Prognosis Unintentional Weight Loss • > 10% of normal body weight • Body Mass Index (BMI) < 22 kg/m 2 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, Mc. Graw 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, Mc. Graw 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, Mc. Graw 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-of. Life Care. New York, Mc. Graw 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. 16

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. 17

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 18

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 19

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-of. Life Care. New York, Mc. Graw 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 21

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 • Po 2 ≤ 55 mm Hg or O 2 saturation ≤ 88% • Pco 2 ≥ 50 mm Hg – Continuous oxygen therapy 22

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-of. Life Care. New York, Mc. Graw 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, Mc. Graw 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-of 25 Life Care. New York, Mc. Graw 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, Mc. Graw 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. 5 mg/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, Mc. Graw Hill, 2001. 27

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, Mc. Graw 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, Mc. Graw 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 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 30

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 31

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 m. L/min (< 15 m. L/min with diabetes) – Serum creatinine > 8 mg/dl (> 6. 0 mg/d. L 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-of. Life Care. New York, Mc. Graw Hill, 2001.

End-Stage Renal Disease • Signs/symptoms of Progressive Uremia – – – Confusion and obtundation Intractable nausea and emesis Generalized pruritis Restlessness Oliguria: urine output < 400 m. L/24 hrs Intractable hyperkalemia: serum potassium > 7. 0, not responsive to medical management – Pericarditis – Intractable fluid overload – Hepatorenal syndrome 33

Acute Renal Failure Co-Morbid illness associated with poor prognosis • Mechanical ventilation • Advanced cardiac • Chronic lung disease • Advanced liver • Sepsis disease • Immunosuppression / • Serum albumin <3/5 g/d. L AIDS • Cachexia • Platelet count • Age > 75 years <25, 000 • Gastrointestinal • Disseminated bleeding intravascular • Malignancy 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 35 – Hepatorenal syndrome

End-Stage Liver Disease • Lab indicators – Protime ≥ 5 seconds more than control – Serum albumin ≤ 2. 5 g/d. L • Other factors – Progressive malnutrition – Muscle wasting with reduced strength and endurance – Continued active ethanol intake (> 80 g ethanol per day) – Hepatocellular carcinoma – Hbs. Ag 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-of. Life Care. New York, Mc. Graw Hill, 2001.

Determining Prognosis End-Stage AIDS • CD 4+ 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 37

End-Stage AIDS Other factors associated with poor prognosis – – Chronic persistent diarrhea for 1 year Persistent serum albumin < 2. 5 g/d. L Age > 50 years Decision to forego antiretroviral therapy, chemotherapy and prophylactic drug therapy related to HIV – Congestive heart failure, symptomatic at rest 38

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/m 2 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 39

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 40