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PROGNOSTICATION IN NON CANCER

Dr Ebru Kaya Palliative Care, UHN TCPCN: Lunch and learn series 16 June 2010

Objectives

· Discuss barriers to prognosticating · Discuss reasons for prognosticating · List common and disease specific tools used for prognostication

· · · · ·

Why prognosticate? Common tools Disease specific tools/models Incorporating into everyday practice Summary

Definition of prognosis

Prediction of possible future outcomes of a disease course based on medical knowledge and experience (Christakis, Uni Chic Press 1999)

Case

· 73 yr female in hosp ­ 4th this year with CHF exacerbation · PMH: COPD, DM · Poor appetite, tired, no pain · ACEI, Statin, Furosemide · Cardiologist ­ expected to survive 12 months · Consulted for eligibility for short term PCU

Case

· · · · · · · · NYHA 3 KPS 40 PPS 40 RR 30 SBP 104 Ur 12 Hgb 110 WCC 10.4 L 13% EF 20%

Case

Patient asks you:

"How long have I got?"

Barriers to prognosticating

· · · · Not competent Uncertain disease trajectory Not wanting to remove hope Time consuming

Barriers to prognosticating

· Survey of 700 US physicians in the late 1990s showed that 60% felt poorly trained in formulating a prognosis (Christakis et al, Arch Int Med 1998) · Lack of formal education on prognosis in med schools, textbooks and journals (Glare and Sinclair, J Pal Med 2008)

Why prognosticate?

· · · · · · Help patients plan realistically for the future Help with clinical decision making Discharge and care planning Initiate hospice/ PCU referrals For research purposes For policy making

Why prognosticate?

· Patients want info about life expectancy · Families are dissatisfied with communication around prognosis. Patients less likely to desire CPR if they feel prognosis is "poor". Patients want realistic prognosis info on background of maintaining hope (Lynn et al, West J Med 1995)

Prognosticating

Components: 1. Estimating the future course of the patients illness 2. Communicating that information with others This seminar will focus on the estimating part rather than the communicating part

Prognosis

Clinician's prediction of survival (CPS)

Actuarial estimation of survival (AES)

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Survival predictions

Temporal

(CPS) 25% accuracy

(pt will live certain amount of time)

Probabilistic

(AES or prognostic indices/tools)

(the % chance of surviving to a certain time)

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Goal

· Formulate an individualised prognosis, starting with a generalised prognosis and modify it according to patient's performance status, symptoms, comorbidities, and knowledge of illness trajectories

Clinician's prediction of survival

Prospective study on cancer patients: · academic oncologists more accurate than community oncologists or GPs and experienced physicians more accurate. · Predictions less accurate if strong patientphysician relationship (Christakis et al, BMJ 2000)

Prognostic tools

Common patient related factors in many: · Performance status (KPS, PPS, AKPS) · Signs and symptoms relating to nutritional status (anorexia, wt loss etc) · Other key symptoms (dyspnoea, confusion) · Biologic parameters (alb, WCC ­LCC ratio)

Performance status measures

KPS PPS AKPS 100% Normal, no evidence of disease, no complaints Able to carry on normal activity; minor signs or symptoms Normal activity with effort; some signs or symptoms of disease Cares for self; unable to carry on normal activity or to do active work Requires occasional assistance but is able to care for most of his needs Requires considerable assistance and frequent medical care Disabled; requires special care and assistance Severely disabled; hospitalization necessary; active supportive treatment is necessary Very sick; hospitalization necessary; active supportive treatment is necessary Moribund; fatal processes progressing rapidly Normal activity & work, no evidence of disease Normal activity & work, some evidence of disease Normal activity with effort, some evidence of disease Cares of self, normal or reduced intake Unable to do hobby/ house work, normal or reduced intake, occasional assistance needed, maybe confused. Mainly sit / lie, considerable assistance needed, maybe confused Unable to do most activity, mainly in bed, mainly assistance, maybe drowsy +/- confused Unable to do any activity, totally bedbound, total care, maybe drowsy +/- confused Totally bedbound, total care, minimal intake to sips, maybe drowsy +/- confused Totally bedbound, total care, mouth care only, drowsy or coma +/- confusion Normal; no complaints; no evidence of disease Able to carry on normal activity; minor signs or symptoms Normal activity with effort; some signs or symptoms of disease Cares for self; unable to carry on normal activity or to do active work Requires occasional assistance but is able to care for most of his needs Requires considerable assistance and frequent medical care In bed more than 50% of the time 90%

80%

70%

60%

50%

40%

30%

Almost completely bedfast

20%

Totally bedfast and requiring extensive nursing care by professionals and/or family

10%

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Comatose or barely arousable

PPS (palliative performance scale)

· Validated in many population groups · Used in cancer and non cancer · Widely used in Canada · Many practitioners are familiar with it (Anderson and Downing, J Pal Care 1996) http://web.his.uvic.ca/research/NET/

PPS

· Shown to have prognostic value · Different studies quote different values PPS 10% - 73% mortality 30 days ­ median 2 days PPS 20% - 68% mortality 30 days ­ median 2 days PPS 40% - 59% mortality 30 days ­ median 20 days PPS 60% - 46% mortality 30 days ­ median 64 days (Lau et al, J Pall Care 2008)

AKPS (Australia-modified Karnofsky performance status) Recent study (process of being published): · 40% non cancer US population, appears to be better at predicting survival at lower end of scale compared with PPS (Abernethy et al, BMC Pall Care 2005)

PaP (Palliative prognostic score) · Good for predicting 30 day survival · Validated in non cancer though studies are small · Combines clinician estimates, performance status, symptoms and lab parameters · Needs further validation and prediction only up to 30 days (Pirovano et al, J Pain Symp M 1999)

PaP

CRITERION ASSESSMENT

No Yes No Yes >30 10 - 20 >12 11 ­ 12 7 ­ 10 5­6 3­4 1-2 <8.5 8.6 ­ 11 >11 20 - 40% 12 - 19.9% < 12%

PARTIAL SCORE

Dyspnea

0 1 0 1.5 0 2.5 0 2 2.5 4.5 6 8.5 0 0.5 1.5 0 1 2.5 TOTAL SCORE 0 - 5.5 5.6 - 11 11.1 - 17.5

Anorexia

Karnofsky Performance Status

Clinical Prediction of Survivial (weeks)

Total WBC (x109/L

Lymphocyte Percentage

RISK GROUP A B C

30 DAY SURVIVAL >70% 30 - 70% < 30%

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Congestive Heart Failure

Difficult to accurately predict short term prognosis: · Unpredictable disease trajectory · High incidence of sudden death (25-50%) · Disparities in applying evidence based guidelines · Inter-observer differences in NYHA · Heterogeneous study population in HF literature (Reisfield and Wilson, J Pall Med 2007)

NYHA classification

1 year mortality (based on data from SUPPORT, Framingham, IMPROVEMENT): · II 5 -10% · III 10 - 15% · IV 30 ­ 40%

Poor prognostic factors

· · · · · · · Cardiac hospitilization Ur Cr 120mol/l SBP 100mmHg HR 100 bpm LVEF 45% Ventricular arrhythmias · · · · · Anaemia Na < 135 mEq/l Cachexia Functional capacity Comorbidities (DM, depression, COPD, cirrhosis, Ca, HIV cardiomypathy)

Models (HF)

EFFECT model (Lee et al, JAMA 2003) · Validated in Ontario hospitals · 30 day and 1 ­yr mortality · www.ccort.ca/CHFriskmodel.asp Seatle HF model (Levy et al, Circulation 2006) · 1,2,3 yr survival estimate · Clinical, lab, medications and device therapies · Needs further validation · www.seattleheartfailuremodel.org

COPD

· Ambulatory patients FEV1 < 35% predicted value = 25% die within 2 years, 55% die within 4 years · BODE scale to help predict 1-3 yr survival (uses dyspnoea, BMI, ex tolerance) (Celli et al, NEJM 2004)

COPD

· Hospitalised patients PaCO2 >50 10% will die on current admission 33% will die within 6 months 43% will die within 1 year (Connors et al, Am J Resp Crit Care Med 1996)

Poor prognostic factors

· Comorbidities · Severity of illness · Albumin · Anaemia · Previous mechanical ventilation · Failed extubation / intubation > 72hr (Childers et al, J Pall Med 2007)

Dementia

Poor prognostic factors (6 month mortality): · Older age · More anorexic · Poor functional status (KPS)

(DMI ­ Schonwetter et al, Am J Hosp Pall Care 2003)

· Advanced dementia (7C of FAST scale) and medical complications and dependency of ADLs

(Luchins et al, Am J Geri Soc 1997)

Dementia

· NHPCO (national hospice and palliative care organisation) recommends FAST (Functional assessment staging tool) · Not all patients follow FAST stages · Limited studies (Lee and Chodosh, J Am Med Dir Assoc 2009)

Functional Assessment Staging (FAST) stages

· · · · · · · 1. 2. 3. 4. 5. 6. 7. No difficulties Subjective forgetfulness Decreased job functioning and organizational capacity Difficulty with complex tasks, instrumental ADLs Requires supervision with ADLs Impaired ADLs, with incontinence A. Ability to speak limited to six words B. Ability to speak limited to single word C. Loss of ambulation D. Inability to sit E. Inability to smile F. Inability to hold head up

MRI (Mortality risk index)

· Validated on newly admitted NH pts · Greater predictive value of 6 month prognosis (compared to FAST) · More quantitative in assessment and reporting (compared to DMI) (Mitchell et al, JAMA 2004)

MRI

· · · · · · · · · · · · Points 1.9 1.9 1.7 1.6 1.6 1.5 1.5 1.5 1.5 1.5 1.4 1.4 Risk factor Complete dependence with ADLs Male gender Cancer Congestive heart failure O2 therapy needed w/in 14 day Shortness of breath <25% of food eaten at most meals Unstable medical condition Bowel incontinence Bedfast Age > 83 y Not awake most of the day

MRI - Risk estimate of death within 6 months

· · · · · · ·

Score 0 1-2 3-5 6-8 9-11 12

Risk % 8.9 10.8 23.2 40.4 57.0 70.0

Neurologic disease

Amyotrophic lateral sclerosis (ALS/MND) Should be included from diagnosis · Sleep disturbance · Dyspnoea at rest · Barely intelligible speech · Difficulty swallowing · Poor nutritional status · Impaired ADLs · Medical complications · Low Vital Capacity (<70% predicted)

Neurologic disease

Parkinsons disease · Drug treatment no longer effective / increasingly complex regime of drug treatments · Impaired ADLs · Dyskinesias, mobility problems and falls · Swallowing problems · Psychiatric signs (depression, anxiety, hallucinations, psychosis)

Neurologic disease

Stroke · Persistent minimal conscious state / dense paralysis / incontinence · Medical complications · Lack of improvement within 3 months onset · Cognitive impairment / post-stroke dementia

Neurologic disease

· Based on Gold standards framework (UK) version 5 September 2008 (developed with input from experts) · No published studies in this area

Case

· What is her prognosis?

Case

· PPS · 20 days median survival or 59% 30 day mortality

· PaP score · EFFECT

· >70% 30 day survival

· 59% 30 day mortality

Summary

· · · · · · · Patients and carers want prognostic info Useful for clinicians Helps with resource allocation General and disease specific tools Not taught well Remains challenging Need more studies

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