USING PALLIATIVE PERFORMANCE SCALE

Transcription

1 USING PALLIATIVE PERFORMANCE SCALE S U A N D O K P A L L I A T I V E C A R E D A Y, J U N E 2 2 t h 2010 G. Michael Downing, MD Clin. Assoc. Prof, U of British Columbia, Fac. of Med. Adj. Ass t Prof, U of Victoria, School of Health Info Science Palliative Medicine; Dir of Res. & Dev.; Victoria Hospice Society

2 WHERE DID COME FROM? In early 1980 s, some oncologists in Canada used Karnofsky Performance Scale In looking at KPS, I liked the structure of 10% changes but it seemed deficient KPS next slide

3 Score Karnofsky Performance Status (KPS) Scale Able to carry on normal activity and to work; no special care needed Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly 100% Normal; no complaints; no evidence of disease 90% Able to carry on normal activity; minor signs or symptoms 80% 70% 60% 50% Normal activity with effort; some signs or symptoms of disease Cares for self; unable to carry on normal work or to do active work Requires occasional assistance but is able to care for most of his personal needs Requires considerable assistance and frequent medical care 40% Disabled; requires special care and assistance 30% 20% Severely disabled; hospital admission is indicated, although death is not imminent Very sick; hospital admission necessary; active supportive treatment is necessary 10% Moribund; fatal processes progressing rapidly 0% Dead Karnofsky et al. The use of nitrogen mustard in the palliative treatment of cancer. Cancer 1948;1:

4 WHERE DID COME FROM? Main problem At KPS 20% it said that hospitalization was necessary But this is not what our palliative program wanted Also, it seemed to me that other factors of intake & conscious level were also important Therefore, I added 2 columns & changed the bottom KPS levels to create

5 Palliative Performance Scale (v2) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ambulation Activity & Self-Care Intake Conscious Evidence of Disease Level Full Normal Activity Full Normal Full No Evidence of Disease Full Normal Activity Full Normal Full Some Disease Full Normal Activity with Effort Full Normal or Full Some Disease Reduced Reduced Unable Normal Job/Work Full Normal or Full Some Disease Reduced Reduced Unable Hobby/House Work Occasional Normal or Full Significant Disease Assistance Reduced +/- Confusion Mainly Sit/Lie Unable to Do Any Work Considerable Normal or Full Extensive Disease Assistance Reduced +/- Confusion Mainly in Bed Unable to Do Any Work Mainly Normal or Full or Drowsy Extensive Disease Assistance Reduced +/- Confusion Total Bed Bound Unable to Do Any Work Total Care Reduced Full or Drowsy Extensive Disease +/- Confusion Total Bed Bound Unable to Do Any Work Total Care Minimal Full or Drowsy Extensive Disease Sips +/- Confusion Total Bed Bound Unable to Do Any Work Total Care Mouth Drowsy or Extensive Disease Care Only Coma Death x x x x

6 WHERE DID COME FROM? v2 has only minor changes in adding confusion at 60% to include early dementia published in 1996 [10 years later] Formal reliability and validity study in 2006

7 USING V2 No tool is perfect One looks horizontally to find the best fit Start at left column and go down until appropriate level Then go the next column and read down to fit Etc A diagonal decline as in next slide

8 Palliative Performance Scale (v2) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Ambulation Activity & Self-Care Intake Conscious Evidence of Disease Level Full Normal Activity Full Normal Full No Evidence of Disease Full Normal Activity Full Normal Full Some Disease Full Normal Activity with Effort Full Normal or Full Some Disease Reduced Reduced Unable Normal Job/Work Full Normal or Full Some Disease Reduced Reduced Unable Hobby/House Work Occasional Normal or Full Significant Disease Assistance Reduced +/- Confusion Mainly Sit/Lie Unable to Do Any Work Considerable Normal or Full Extensive Disease Assistance Reduced +/- Confusion Mainly in Bed Unable to Do Any Work Mainly Normal or Full or Drowsy Extensive Disease Assistance Reduced +/- Confusion Total Bed Bound Unable to Do Any Work Total Care Reduced Full or Drowsy Extensive Disease +/- Confusion Total Bed Bound Unable to Do Any Work Total Care Minimal Full or Drowsy Extensive Disease Sips +/- Confusion Total Bed Bound Unable to Do Any Work Total Care Mouth Drowsy or Extensive Disease Care Only Coma Death x x x x

9 HOW MANY LANGUAGES? English French Japanese Thai Portuguese Spanish & Catalan - current reliability testing German Arabic

10 USES OF V2 Communication Verbal Charting Service allocation Plan P Registration Service monitoring eg. LOS Workload eg. Home Care and weekend visits Prognosis Care models Eg. Suandok Collaborative Care Cancer Care Ontario, Canada Psychosocial transition support Research demographic, prognostic, etc

11 IS V2 RELIABLE? Reliability study in Victoria Reliability study in Chiang Mai study Validation by other programs Australia Dr. P Glare Japan Dr. Morita US Dr. Olajide (N. Carolina); Dr Harrold (U of Kentucky); Dr. Head (Pennsylvania)

12 REFERENCES 1. Downing M, Lesperance M, Lau F, Yang J. Sudden functional decline as a sentinel event using the Palliative Performance Scale in survival prediction. J Pall Med [in press 2010]. 2. Dudgeon, Knott, Chapman et al. Development, implementation, and process evaluation of a regional palliative care quality improvement project. J Pain Symptom Manage. 2009;38(4): Lau F, Downing M, Lesperance M, Karlson N, Kuziemsky C, Yang J. Using the Palliative Performance Scale to provide meaningful survival estimates. J Pain Symptom Manage Jul;38(1): Lau F, Maida V, Downing M, Lesperance M, Karlson N, Kuziemsky C. Use of the Palliative Performance Scale () for end-of-life prognostication in a palliative medicine consultation service. J Pain Symptom Manage Jun;37(6): Campos S, Zhang L, Sinclair E, Tsao M, Barnes EA, Danjoux C, et al. The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic. Supportive Care In Cancer: Official Journal Of The Multinational Association Of Supportive Care In Cancer. 2009;17(6): Lau F, Bell H, Dean M, Downing M, Lesperance M. Use of the Palliative Performance Scale in survival prediction for terminally ill patients in Western Newfoundland, Canada. J Palliat Care Winter;24(4): Ho F, Lau F, Downing M, Lesperance M. A validity and reliability study of the Palliative Performance Scale. BMC Palliative Care. 2008;7(10). 8. Maida V, Lau F, Downing M, Yang J. Correlation between Braden Scale and Palliative Performance Scale in advanced illness. International Wound Journal Oct;5(4): Lau F, Cloutier-Fisher D, Kuziemsky C, Black F, Downing M, Borycki E, et al. A systematic review of prognostic tools for estimating survival time in palliative care. J Palliat Care. 2007;23(2): Downing M, Lau F, Lesperance M, Karlson N, Shaw J, Kuziemsky C, et al. Meta-analysis of survival prediction With Palliative Performance Scale. J Palliat Care. 2007;23(4):

13 11. Olajide O, Hanson L, Usher BM, Qaqish BF, Schwartz R, Bernard S. Validation of the palliative performance scale in the acute tertiary care hospital setting. J Pall Med. 2007;10(1): Lau F, Downing GM, Lesperance M, Shaw J, Kuziemsky C. Use of Palliative Performance Scale in end-of-life prognostication. Journal of Palliative Medicine Oct;9(5): de Miguel Sanchez C, Elustondo SG, Estirado A, Sanchez FV, de la Rasilla Cooper CG, Romero AL, et al. Palliative performance status, heart rate and respiratory rate as predictive factors of survival time in terminally ill cancer patients. Journal of Pain & Symptom Management. 2006;31(6): Wilner LS, Arnold RM. The Palliative Performance Scale #125. Journal of Palliative Medicine. 2006;9(4): Head B, Ritchie CS, Smoot TM. Prognostication in hospice care: can the palliative performance scale help? Journal of Palliative Medicine. 2005;8(3): Harrold J, Rickerson E, Carroll JT, McGrath J, Morales K, Kapo J, et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? Journal of Palliative Medicine. 2005;8(3): Hilliard RE. The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Journal of Music Therapy. 2003;40(2): Virik K, Glare P. Validation of the palliative performance scale for inpatients admitted to a palliative care unit in Sydney, Australia. Journal of Pain & Symptom Management. 2002;23(6): Morita T, Tsunoda J, Inoue S, Chihara S. Terminal sedation for existential distress. The American Journal Of Hospice & Palliative Care. 2000;17(3): Fainsinger RL, Demoissac D, Cole J, Mead-Wood K, Lee E. Home versus hospice inpatient care: discharge characteristics of palliative care patients in an acute care hospital. Journal of Palliative Care. 2000;16(1): Morita T, Tsunoda J, Inoue S, Chihara S. Validity of the palliative performance scale from a survival perspective. Journal of Pain & Symptom Management. 1999;18(1): Anderson F, Downing GM, Hill J, Casorso L, Lerch N. Palliative performance scale (): a new tool. J Palliat Care. 1996;12(1):5-11.

14 COMMUNICATION

15 Unit Rounds Room Nurse Team assignments Patient Names

16 Room # % Bed Type Family Doctor Mrs. L Mrs. S Mrs. E Miss. J Mr. B Miss B Mr. J Patient Name Room # 311 Mrs. S. with 50% Admitted to A Acute palliative bed Reason: metastatic cancer breast with severe lumbar bone pain

17

18 SERVICE ALLOCATION

19 USED AS A CRITERIA Registration with some palliative programs at 60% BC Drug Benefits Plan P One criteria is 50% Home Care Nursing If a palliative patient 30% or less, then automatic schedule a weekend nursing visit

20 PROGNOSTICATION

21 MULTIPLE RESEARCH STUDIES Several studies show to be a strong predictor of survival in already identified palliative patients Ie. The patient already has an advanced or terminal illness Not tested in non-palliative [but Chiang Mai hospital is using in all wards!!!]

22 KM-Curves % Survival 1. Patients in Crisis (unstable) VHS Unit & Home (PRT) - 6,066-1 st Downing, Lau, Lesperance et al. J Pain Sympt 2009 Jul;38(1): Log rank p < Pair-wise log rank X 2 <0.001 i.e. admit to PCU or PRT M. Downing

23 2. Survival Table (%) in days Lau, Downing et al. J Pain Sympt Management July;38(1) 70% 60% 50% 40% 30% 20% 10% M. Downing Survival Rate (%) in Days Total Cases 99% 97% 96% 95% 87% 77% 62% 51% 35% 16% 7% % 97% 95% 92% 83% 64% 49% 41% 29% 12% 5% % 93% 87% 82% 67% 47% 36% 28% 19% 8% 4% 1,055 94% 82% 73% 66% 46% 27% 19% 15% 9% 4% 1% 1,647 84% 63% 48% 40% 23% 12% 8% 6% 4% 2% 1% 1,420 56% 28% 15% 9% 4% 2% 2% 1% 1% 0% 0% % 13% 5% 3% 1% 0% 0% 0% 0% 0% 0% 570 Indicates approx. Median survival rate of 50%

24 Mary, we don t know for sure how long John may live, but as he has just come into the Unit (at 40%), about ½ of Lau, Downing et al. J Pain Sympt Management July;38(1) patients like him live > 2 wks, but ½ will also die sooner Survival Rate (%) in Days Total than that Cases are only a very 99% 97% 96% 95% 87% There 77% 62% 51% 35%few16% 7% % (about 1%) who will live 1 year, In fact, about 1/3 of but it is possible some patients in < 7 95% 92% 83% 64% 99%die 97% 49% 41% for29% 12% 5% % days 97% 93% 87% 82% 67% 47% 36% 28% 19% 8% 4% 1,055 50% 94% 82% 73% 66% 46% 27% 19% 15% 9% 4% 1% 1,647 40% 84% 63% 48% 40% 23% 12% 8% 6% 4% 2% 1% 1,420 30% However, he has2%become 56% John 28% now 15% has 9%pneumonia, 4% 2% 1% 1% 10% 0% of0% 737 patients 20% very confused and is quite short of breath I think he is will live for 3 on the short side of 2 weeks and I m not even sure or more 34% 13% 5% 3% 1% 0% 0% 0% 0% months 0% 0% % about this week what do you think? Let s talk again tomorrow; we may know more then Indicates approx. Median survival rate of 50% M. Downing 2. Survival Table (%) in days

25 Victoria Research 3 Points 1. Sudden drop is not good Sudden drop as sentinel event within first 3 days admission to PCU [# cases 3,349 in 13-year data] More likely to drop at least one level if: 1. Men vs women p= Older vs younger p= Lower on admission p=0.000 [ then 80%; then 30%] 4. Disease signif. but not strong p= [non-cancer 50% vs cancer 39-45%] 5. Tertiary bed vs LTC bed p=0.000 Point 1 of 3

26 2. Higher increment drop = shorter survival [using 40% here as example] Overall survival KM-graph for 6,000 Pts Sentinel event occurs at 40% Survival Curves for Sentinel Even Survival probability % [now black] with no drop within 3 days admission to PCU with 10% drop to 30% with 20% drop to 20% with 30% drop to 10% with 40% drop to 0% Point 2 of 3

27 Sudden Functional Drop JOURNAL OF PALLIATIVE MEDICINE Volume 13, Number 5, The lower the initial at admission, the higher the likelihood of an abrupt drop 2. An abrupt decline in function appears to imply shorter survival. 3. The greater the increment change in, the shorter the likelihood of survival 4. The lower the on admission, the shorter the likelihood of survival. 5. When dropping a specific increment amount, the new survival projection appears similar to the level dropped to. 6. Sudden or abrupt functional decline may be a sentinel event.

28 CARE MODELS

29 VICTORIA HOSPICE Forms the basis of our palliative program and service Used in cancer and non-cancer patients was intended for palliative patients but can bed used as a functional assessment tool in others Eg. Maharaj Nakorn in all hospital wards

30 11-Levels 100% 90% 80% 70% CHPCA 2-Phases Active: reduce disease Cancer Care Ontario PCIP Pall Care Integration Project 3-Groups Collaborative Care Plan Stable 70% Australia PCOC Pall Care Outcomes Collaborative 5-Phases Stable Australia Population Based Palliative Model 3-Groups Complex 60% Unstable Intermediate 50% 40% 30% 20% 10% 0% Palliative: reduce suffering Transitional 40%-60% End-of-Life 30% Deteriorating Terminal (days) Bereavement Primary Care M. Downing

31 CONCLUSION v2 is a valuable tool You can use v2 Adult Suandok if you would like to Dr Busyamas and research team at Chiang Mai are completing a reliability and validity study, available shortly [preliminary looks good!!]