Prognostication in End of Life

Transcription

1 Prognostication in End of Life Janet Bull, MD FAAHPM Four Seasons Course Handouts & Post Test o To download presentation handouts, click on the attachment icon o Presenter discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN. o This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Disclosures o Scientific Advisory Board Salix Archimedes o Speakers Bureau Salix Meda Pfizer 1

2 Objectives o Describe how dying has changed o Describe the 4 common pathways to death o Identify the common denominators to decline which are universal despite diagnosis o List important prognostic factors for specific disease categories o Discuss when to refer patients to hospice and palliative care based upon prognostic information How Dying Has Changed - US Pneumonia 1. Heart Disease 2. Tuberculosis 2. Cancer 3. Diarrhea and Enteritis Life expectancy: 47 years Disability: Days to Weeks 3. Pulmonary Disease 78.2 years Weeks to Years Chronic Disease o Nearly 1 in 2 Americans has a chronic disease o Projected to increase 157 million Americans by 2020; 171 million by 2030 o Americans are living longer from 2010 to 2030 > 65 years old increase 13.2% to 20% o 90% seniors have at least one chronic disease, 77% have 2 o 24% of those with chronic illness disability Chronic Conditions: Making the case for ongoing care. RWJ 9/2004 update 2

3 Prognosis o Provides framework to make informed decisions about care o Provides life-care planning spiritual financial psychosocial relationships/forgiveness opportunity to say goodbye life closure and legacy giving 7 Discussion of Prognosis and Goals Leads to Different Medical Care in the Last Week of Life Wright, A. A. et al. JAMA 2008;300: Copyright restrictions may apply. Costs Go Down 48 Hours After Palliative Care Consultation Mean direct costs/day for patients who died and who received palliative care consultation versus matched usual care patients Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only. 3

4 Prognostication in Cancer o 50% < 6 month survival o Systemic review 383 articles o Universal picture of decline o Little evidence that treatment influenced survival time o Hospice - median survival time - 3 wks Salpeter,S. Systemic Review of Cancer Presentations with a median survival of 6 months or less JPM Vol 14, 2011 Prognostication in Non Cancer o Universal factors - 50% 6 mo mortality Poor performance status Advanced age Malnutrition Comorbidites Organ Dysfunction Hospitalization for acute decomposition o Treatment did not improve prognosis Salpeter,S Systematic Review of Noncancer Presentations with a median survival of 6 months or less AJMed 2011 Prognosis o Diagnosis is it terminal? severity of disease co-morbidities worsening symptoms functionally dependent rehab potential poor progressive rate of decline o Treatment maximal 12 4

5 Prognosis - Overestimate o 326 patients with cancer in 5 Chicago hospices o 20% accuracy in predicting prognosis o 63% overestimate, 17% underestimate o Only 37% would give frank disclosure, even when patient requested survival estimate o Average survival time was 26 days; average communicated survival time was 90 days o Closer the relationship more likely to err Christakis, Annals of Int Med, Prognostication for the Generalist Would you be surprised if this patient died within the next year? Lynn, 2005 What is the Clinical Course? A Disease - Stable Years B C D Disease - Unstable Months Deteriorating, Exacerbations Weeks End of Life Days Gold Framework Standard Prognostic Indicator

6 Disease Trajectories/ADLs o Sudden death o Cancer o Organ Failure o Frailty 1/12 Sudden Death 1/4 Cancer Frailty / Dementia Organ Failure 1/3 1/3 Prognostic Indicator Paper, Gold Standards Framework, England Cancer o Accounts for 30 % of all deaths o Highly functional early on with slow steady decline 3 months prior to death 1 year prior to death -.77 ADL 3 months prior to death ADL 17 Disease Trajectories High "Cancer" Trajectory, Diagnosis to Death Cancer Function Death Low Onset of illness Decline usually 3 months 18 6

7 Organ Failure o Account for 40% of all deaths o Multiple exacerbations, often frequent hospitalizations o Generally die during exacerbations o Renal, liver, cardiac, pulmonary o Functional status fluctuates with overall slow decline 1 year prior to death 2.1 ADL 3 months prior to death 3.66 ADL 19 Disease Trajectories High Organ System Failure Trajectory Function (mostly heart and lung failure) Death Low Multiple hospitalizations Death usually follow disease exacerbation Time frame usually 2-5 years 20 Frailty o Accounts for 20-30% of all deaths o Elderly women with multiple co-morbidities o Dementia often present o Very slow rate of decline, with early functional decline 1 year prior to death 2.92 ADL 1 month prior to death 5.84 ADL 21 7

8 Disease Trajectories High Frailty / Dementia Trajectory Function Death Low High dependence on ADLs Slow decline early in disease course Time frame- usually 6-8 years 22 Prognosis Important factors to consider o Co-morbid illnesses o Rate of decline o Nutritional status o Functional status o Cognitive status o Age and gender o Number of hospitalizations in past year o Will to live o Other (psychosocial, emotional and spiritual) 23 Depression and Social Isolation o Increased rates of hospitalization o Increased mortality post MI o Increased mortality from cancer o Overall higher mortality rates from all diseases o Lower immune functions o Depression and social isolation independent risk factors 24 8

9 Spiritual Beliefs and Prognosis o Major source of coping 85% hospitalized pts 40% most important factor o Multiple studies in chronic diseases demonstrate source of coping o Suggested role in improving depression o Literature demonstrates beneficial effects on health outcomes Prognostication Tools o LCDs o Disease Specific Tools (FAST, MRI, BODE, MELD, NYHA, Albumin, Cr cl, BNP, CO2) o BMI/weight o ADLs o MMSE/clock drawing o PPS/Karnofsky o Rapidity of decline o Co-morbidities o Secondary conditions 26 Prognostic Tools - Advanced Disease o Prognostat age, gender, diagnosis, PPS o Palliative Prognostic Score (PaP) FF #124 KS, WBC, lymphocytes, clinical, anorexia, dyspnea o Palliative Prognostic Index (PPI) PPS, edema, oral intake, dyspnea, delirium in cancer patients 27 9

10 Prognosis o Co-morbidities associated conditions not related to the primary illness Dementia patient cardiac disease, pulmonary, etc. o Secondary conditions conditions directly related to the primary diagnosis Dementia patient delusions, dysphagia, pressure ulcers 28 Leading Causes of Mortality Cardiac disease 2. Cancer 3. Respiratory Disease 4. Stroke 5. Accidents 6. Dementia 7. Diabetes 8. Influenza and pneumonia 9. Renal disease National Vital Statistics Report NHPCO - Diagnosis o Cancer 40.1% o Non Cancer 59.9% Debility 13.1% Cardiovascular 11.5% Dementia 11.2% Respiratory 8.2 % Stroke or Coma 4.0% Renal 3.8% Non ALS 1.9% Liver 1.8% ALS.4% HIV-.4% Other 4.5% 30 10

11 Question # 1 62 yo with Class IV heart disease, COPD, DM, and CRF admitted to ICU with ventricular dysrhythmias. EF - 40%, FEV1-40%, Cr-1.5 Would you admit this patient to hospice? 1. Yes, cardiac disease 2. Yes, COPD 3. Yes, diabetes 4. Yes, debility 5. No 31 Physiology of CHF o Systolic 2/3 CAD, 1/3 valvular disease, DM, Hypertension, thyroid, alcoholism and myocarditis o Diastolic CAD and Hypertension 50% CHF over 70 yo Dilated ventricles o Symptoms fatigue and dyspnea o Maladaptive neurohormonal response o TNF and IL-6 cause proteolysis and wasting, similar to cancer pt Journal of Cardiac Failure, vol 13, No Cardiovascular Disease o Cachexia o Depression o Multiple admissions o Co-morbidities DM, PVD, renal, dementia o Age > 70 o Poor functional status o HR > 100, Cr >2, inc sustained BNP o LV volume > 85 mm (20% 2 year survival) Palliation in heart failure, Davis, AJHPM 2005: 22,

12 Cardiovascular Disease o Recent cardiac hospitalization (3 x 1 yr mortality) o Elevated creatinine >1.4 o SBP <100 or tachycardia > 100 (2 x 1 yr mortality) o LVEF < 40% o Ventricular dysrhythmias o Anemia o Hyponatremia o Cachexia o Reduced functional state o Co-morbid illnesses Fast Fact Concept #143 from 11 different studies 34 Cardiovascular Disease o Frequent ER visits/ hospitalizations o Symptoms at rest o Dependence on ADLs o Wt loss >10% o Albumin < 2.5g/dl o EF <20% o Arrhythmias o Previous CPR o Syncope o Embolic stroke Adler, Circulation 2009;120: PC in the treatment of advanced HF CHF Prediction Models o CVM-HF PREDICTOR Am J Cardiol 2006;98: Predicts death at 30 days and one year o SEATTLE HEART STUDY Circulation 2006:113: Levy et al. The Seattle Heart Failure Model: Prediction of Survival in Heart Failure Predicts 1, 2, 3 year survival with and w/o meds 36 12

13 Seattle Heart Model 37 Biomarkers in Heart Disease o Troponin myocardial cell damage o BNP LV dysfunction o Cystatin C renal function o CRP inflammation Increased risk of death when all four elevated NEJM 5/2008 Zetheilius o Others - TNF, IL-6, IL-1, Fas (APO-1), endothelin- 1, NE, troponin-1, Na Biomarkers in Heart Failure, NEJM, Vol 358; Prognostication in Cancer o Performance or functional status Karnofsky Score < 50% ECOG Score > 2 o Solid tumor, KS 50% - average 3-month o KS 60% - average 6 months o Signs and symptoms anorexia confusion or delirium dysphagia dyspnea o Biomarkers Ca-125, Ca 19-9, Ca 27.29, Ca

14 Prognostication in Cancer o Hypercalcemia (exc breast CA and MMyeloma) o Carcinomatous meningitis o Malignant pleural effusion o Pericardial effusion o Liver metastasis o Brain metastasis 40 Question # 2 Case Study 62 yo with COPD, 2 lb weight loss over the past year with a BMI of 24 who is referred to hospice because of increasing dyspnea while ambulating. Patient on oxygen and PPS is 70%. FEV1 is 35% and O2 sat on room air is 89%. Would you admit to hospice? A. Yes B. No 41 COPD - Prognosis BODE point system o Body Mass Index (BMI < 21) o Obstruction FEV1 o Dyspnea scale (MMRC) o Exercise capacity 6 min distance walked Better predictor than FEV1 alone, but still not predictive of 6-month prognosis NEJM, (10)

15 COPD Prognosis o Dyspnea < 50 feet o Depression o Unmarried o Recurrent hospitalizations o Co-morbid illness o FEV1 <30% o Functional decline o Advanced age Hansen-Flaschen COPD, the last year of life. Resp Care 2004;49(1): COPD o Potential Biomarkers Fibrinogen CRP IL-6 TNF IL-1 Int J Chron Obstruct Pulm Dis 2009; 4: Dahl Resp and Critical Care Vol 175 pp Dahl COPD Prognosis Hosp COPD o Meta analysis Need 3 of below Age > 70 Evidence of cor pulmonale History of intubation/vent PPS < 60% or > 3 ADLs Home health needed post hosp Malnutrition albumin <2.5 Serum Cr > 2 Salpeter,S Systematic Review of Noncancer Presentations with a median survival of 6 months or less AJMed

16 Acute Ischemic Stoke 85% CVA s o Thrombotic or embolic o 5% hospital mortality o 17-21% 90 day mortality o Medical complications in the hospital double mortality o NIHSS and age strongest predictors NINDS 12/1995 Tissueplaminogen for acute ischemic stoke Bae, Stroke 7/2005 In Hospital complications and long term mortality Nedeltchev Swiss Med WkLY 2010;140 (17-18) Predictors of early mortality after acute stroke Hemorrhagic Stoke 15% CVA o 52% 30 day mortality o 90% 30 day mortality if brain stem o Volume of bleed matters <30ml 20% mortality ml (100% Rankin score>4 unable to walk or any ADL s without assistance) >60 ml 90+% mortality JAMA Mitka Hemorrhagic stoke guidelines issued Biomarkers Stroke o Copeptin o TNF o IL6 o CRP o ESR Molecular Biomarkers in Stroke Diagnosis and Prognosis Biomark Med 2009,1 August

17 Traumatic Brain Injury o Poor predictors for 6 month survival Age >70 No pupillary reflex Hypoxia Hypotension CT results I-V SDH or EDH Motor Score Lab glucose and Hgb Steyerberg PLoS Med 5(8):e145 Predicting outcome after Traumatic Brain Injury; pro 2008 Amyotrophic Lateral Sclerosis o Prospective study 180 patients Median survival from onset of sx 32 mo Median survival from diagnosis 19 mo o Factors with worse outcome Older age Bulbar features Short time from symptoms to diagnosis Single Prognosis in ALS; a population based study,del Agulila Neurology 2003;60: Amyotrophic Lateral Sclerosis o Consensus panel - Hiroshi Mitsumoto, MD o Recommendations for hospice Family initiates discussion on hospice Severe psychological or spiritual distress Pain requiring high doses of analgesics Dysphagia requiring feeding tubes FVC 50% Loss of function in 2 body regions Completing the Continuum of ALS Care A Consensus Document,

18 Question # 3 Case Study 86 yo WF with Fast Stage 6 dementia who falls at the NH and fractures a hip. Post op she is stable, eating about 20%. A hospice consult is requested. Would you admit this woman to hospice and under what diagnosis? 1. Yes, dementia 2. Yes, debility 3. No 52 Prognosis in Dementia o FAST 7c 39.5 % mortality in 6 mo (poor selectivity) 22.2% who died had FAST 7c (poor sensitivity) Excluded a substantial portion of patients who died in 6 months 77.8% 53 Mortality Risk Index o Retrospective study based on MDS o Better outcome predictor than FAST scale 7c o Assesses 12 risk factors and assign points o Use in nursing home population Mitchell, JAMA 2004:291:

19 Mortality Risk Index - Dementia Complete dependence with ADLs 1.9 Male Gender 1.9 Cancer 1.7 CHF 1.6 Oxygen therapy past 14 days 1.6 SOB 1.5 <25% po intake 1.5 Unstable medical condition 1.5 Bowel incontinence 1.5 Bedfast 1.5 Age > 83 yo 1.4 Sleeps most of the day Mortality Risk Index Risk of estimate of death in 6 months o 0 pts 8.9 % o % o % o % o % o >_ % Mitchell, SL, JAMA 2004, vol 291, Prognosis in Dementia o Hospitalized with pneumonia 53% 6-month mortality vs. 13% cognitively intact o Hospitalized with hip fracture 55% 6-month mortality vs. 12% cognitively intact Morrision RS JAMA 2000;264:

20 Liver Disease NHPCO guidelines PT > 5 or INR >1.5 o Serum albumin < 2.5 gm/dl And at least one of these o Ascites - refractory to treatment o Spontaneous bacterial peritonitis (1 yr surv 30%) o Hepatorenal syndrome o Hepatic encephalopathy o Recurrent variceal bleeding Liver Disease o Calculate MELD score (Model ES Liver Dz) INR Bilirubin Creatinine 59 Liver MELD Scores 3 Month Mortality (Hospitalized) MELD Score Death Rate MELD Na better predictor of those with Heptocellular Carcinoma (over MELD) Kamath

21 Question # 4 Case Study 92 yo with frailty, weight loss (90 lbs), recent history of pneumonia, mild dementia, DM, PVD and CRF. Albumin 2.0, Cr 1.9, Hgb Patient resides in NH; hospice consult requested. Would you admit? 1. Yes, renal disease 2. Yes, dementia 3. Yes, FTT 4. Yes, debility 5. No 61 Chronic Renal Failure Stages GFR 1 slight > 90ml/min 2 mild moderate severe end stage <15 diabetics <10 non diabetics Hemodialysis withdrawal Median survival = 9.6 days, 32% > 2 weeks 62 Renal Disease o Not seeking dialysis or renal transplant o Cr cl < 10 cc/min (15 cc/min with DM) or Cr > 8 mg/dl o Albumin < 3 o Co-morbid conditions PVD, especially amputation CHF DM o Malnutrition o Age > 80 years old 63 21

22 Case Study # 5 Case Study 88 yo with mild CHF, mild dementia, who is referred to hospice for weight loss, poor nutrition, general decline, and multiple hospitalizations for infections o Admit? o What diagnosis? 64 Debility (Ill Defined Condition) o Primary contributing illness o Progressive malnutrition o Dysphagia o KPS < 70% o Dependence of < 2 ADL s o Increase in ER visits/hospitalizations o Co-morbidities 65 Failure to Thrive o BMI < 22 and declining nutritional state o KPS or PPS 40 % o Anthropometric measurements support dx Nutritional impairment and disability are the hallmark features 66 22

23 Documentation Paint the Picture o Primary illness - maximally treated o Co-morbidities list stage of disease, ie dementia with FAST 6 o Secondary conditions o Nutritional o Functional Rate of decline o Cognitive o ADLs o Infections o Signs and symptoms/supporting labs In Summary Would you be surprised if this patient died within the next year? Questions? jbull@fourseasonscfl.org Four Seasons Center of Excellence o Consulting Hospice, Palliative Care & Research o Palliative Care Immersion Course o Mentoring physicians, nurse practitioners and physician assistants 23

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