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Deciding When Hospice is Needed for Patients with Advanced Cancer & Non-malignant Diagnoses. Barry M. Kinzbrunner, MD. Care of the Terminally Ill. “ At each stage in an illness, the physician must ascertain whether a fatal outcome is inevitable….”

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deciding when hospice is needed for patients with advanced cancer non malignant diagnoses

Deciding When Hospice is Needed for Patients with Advanced Cancer & Non-malignant Diagnoses

Barry M. Kinzbrunner, MD

care of the terminally ill
Care of the Terminally Ill

“At each stage in an illness, the physician must ascertain whether a fatal outcome is inevitable….”

Isselbacher KJ, Adams RD, Braunwald E, et al: The Practice of Medicine. In: Isselbacher KJ, Adams RD, Braunwald E, et al (eds): Harrison’s Principles and Practice of Medicine, 9th edition. New York: McGraw Hill, 1980.

medicare hospice benefit
Medicare Hospice Benefit

Terminal Illness: “A medical prognosis (of a) life expectancy of six or months or less of two physicians, if the illness runs its normal course.”

medicare hospice benefit1
Medicare Hospice Benefit

Benefits Protection and Improvement Act (BIPA) 2000

Certification of terminal illness of an individual who elects hospice “shall be based on the physician’s or medical director’s clinical judgement regarding the normal course of the individual’s illness.”

general guidelines
General Guidelines

Clinical Progression of Disease

  • Multiple Hospitalizations, ED visits, or increased use of other health care services
  • Serial physician assessments, laboratory or diagnostic studies consistent with disease progression
  • Changes in MDS in LTC facilities
  • Progressive deterioration identified by home health care

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.

general guidelines1
General Guidelines

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 2-3months
  • 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.

general guidelines2
General Guidelines

Unintentional Weight Loss

  • > 10% of normal body weight
  • Declining Body Mass Index (BMI)
    • < 22 kg/m2
  • Anthropomorphic measures
    • Triceps skin fold thickness
    • Mid-arm muscle area (MMA)
  • Low serum albumin levels
    • Limited utility

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.

general guidelines3
General Guidelines

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.

cancer
Cancer
  • 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.

cancer category 1
Cancer: Category 1

Characteristics

  • Stage IV or metastatic spread
  • Cure potential high to moderate
  • Hospice is indicated when there is disease progression after extensive anti-cancer therapy

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.

cancer category 11
Cancer: Category 1

Treatable with High probability of cure

  • Testicular carcinoma
  • Choriocarcinoma and trophoblastic malignancies
  • Childhood acute lymphoblastic leukemia
  • Other pediatric malignancies
  • Acute promyelocytic leukemia
  • Hodgkin’s 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.

cancer category 2
Cancer: Category 2

Characteristics

  • Cure potential low
  • Complete remission probability for 1-2 years high to moderate
  • Anti-neoplastic therapy in Stage IV disease improves quality and length of life
  • Hospice is indicated when there is disease progression following first or second-line therapy (depending on the primary cancer type)

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.

cancer category 21
Cancer: Category 2

Treatable, high probability remission

  • Adult acute myeloblastic and acute lymphoblastic leukemias
  • Intermediate and high-grade non-Hodgkin’s lymphomas
  • Small cell (oat cell) bronchogenic carcinoma (lung cancer)

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.

cancer category 3
Cancer: Category 3

Characteristics

  • Stage IV or advanced metastatic disease
  • Incurable
  • Remission probability moderate to high
  • Indolent course with long prognosis
  • Anti-neoplastic therapy relatively side-effect free (I.e. hormone therapy)
  • Hospice indicated when there is evidence of disease progression after one or more treatement regimens (depending on cancer type) of standard anti-neoplastic therapy

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.

cancer category 31
Cancer: Category 3

Treatable, incurable with favorable prognosis

  • Prostate carcinoma
  • Breast carcinoma
  • Chronic lymphocytic leukemia
  • Chronic myelocytic leukemia and myeloproliferative disorders
  • Low-grade non-Hodgkin’s lymphomas
  • Multiple myeloma and related disorders
  • Myelodysplastic syndrome
  • Thyroid cancer (except anaplastic)

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.

cancer category 4
Cancer: Category 4

Characteristics

  • Stage IV or advanced metastatic disease
  • Incurable
  • Responses to chemotherapy in < 50% of patients treated
  • Prognosis is not long (often less than 6-12 months) even after response to first line chemotherapy
  • Hospice could be considered as a therapeutic option alongside second line chemotherapy, especially for patients with a poor performance status (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.

cancer category 41
Cancer: Category 4

Treatable in a minority of patients with a less favorable prognosis

  • Non-small cell bronchogenic cancer (lung cancer)
    • Squamous cell
    • Adenocarcinoma
    • Large cell carcinoma
    • Bronchioalveolar carcinoma
  • Esophageal carcinoma
  • Gastric carcinoma
  • Pancreatic carcinoma
  • Soft-tissue sarcomas

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.

cancer category 42
Cancer: Category 4

Treatable in a minority of patients with a less favorable prognosis

  • Primary brain tumors:
    • glioblastoma
    • grade III astrocytoma
  • Gynecological malignancies other than ovary
    • Cervical
    • Endometrial
  • Colorectal cancer
  • Head and neck cancer

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.

cancer category 5
Cancer: Category 5

Characteristics

  • Stage IV or advanced metastatic disease
  • Incurable
  • Generally considered unresponsive or very poorly responsive (< 10-15% of patients) to standard chemotherapy
  • Patients may be eligible for investigational therapy
  • Hospice may be considered the treatment of choice for this group of patients, especially if they do not qualify for investigational therapy

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.

cancer category 51
Cancer: Category 5

Generally unresponsive to standard therapy

  • Renal cell carcinoma
  • Malignant melanoma
  • Hepatobiliary and gall bladder carcinomas
  • Adrenal carcinoma
  • AIDS associated high-grade lymphoma

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.

end stage cardiac disease
End-stage Cardiac Disease
  • Dyspnea and/or chest pain at rest or with minimal exertion (NYHA Class IV)
    • Ejection Fraction < 20% helpful if available
  • Optimal medical therapy with vasodilators and diuretics or
  • Inability to tolerate optimal medical therapy due to hypotension and/or renal insufficiency
  • 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.

end stage cardiac disease1
End-stage Cardiac Disease

Other indicators of a poor prognosis

  • Symptomatic arrhythmias resistant to anti-arrhythmic therapy
  • History of prior 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.

end stage pulmonary disease
End-stage Pulmonary Disease

Disabling dyspnea as demonstrated by:

  • Dyspnea at rest or with minimal exertion
  • Dyspnea poorly responsive to bronchodilators
    • FEV-1 < 30% predicted, post-bronchodilator

Progressive pulmonary disease as manifested by:

  • Multiple hospitalizations, ER visits, or doctor’s office visits
  • Cor pulmonale

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.

end stage pulmonary disease1
End-stage Pulmonary Disease

Other indicators of a poor prognosis

  • Body weight
    • < 90% ideal body weight or
    • > 10% weight loss
  • Resting tachycardia > 100/min
  • Abnormal ABG’s or O2 saturation
    • pO2 < 55 mm Hg
    • O2 saturation < 88%
    • pCO2 > 50 mm Hg
  • Continuous oxygen therapy

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.

dementias and other end stage neurodegenerative disorders
Dementias and other End Stage Neurodegenerative Disorders

FAST Stage 7

  • Inability to ambulate without assistance
  • Inability to speak or communicate meaningfully
    • Speech limited to 6 or fewer intelligible words
  • Loss of ADL functions including bathing and dressing (Stage 6)
  • Incontinence of bowel and bladder (Stage 6)

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.

dementias and other end stage neurodegenerative disorders1
Dementias and other End Stage Neurodegenerative Disorders

Patient has had one or more of the following in the last 6-12 months

  • Aspiration pneumonia
  • Pyelonephritis or upper urinary tract infection
  • Septicemia
  • Decubitus ulcers: Stage III or IV
  • Fever, recurrent, after antibiotics
  • Altered nutritional status

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.

dementias and other end stage neurodegenerative disorders2
Dementias and other End Stage Neurodegenerative Disorders

Altered nutritional status

  • Difficulty swallowing or refusing to eat
    • Caloric intake cannot be maintained
    • Patient/family refuses artificial nutritional support
  • If patient is already receiving artificial nutritional support
    • Weight loss > 10% of normal body weight
    • Decreasing Body Mass Index (BMI) < 22 kg/m2
    • Decreasing mid-arm muscle area (MMA)

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.

prognostic accuracy of dementia guidelines
Prognostic Accuracy of Dementia Guidelines
  • FAST 7-C
    • Median survival of < 6 months irrespective of interventions for co-morbid conditions
  • More cognitively intact than 7-C
    • Median survival of almost 2 years
  • FAST 7 with non-sequential progression through sub-stages A-C
    • Median survival < 6 months if no acute medical interventions for co-morbid conditions or inter-current illnesses
    • Median survival 14-15 months if provided with acute medical interventions for co-morbid conditions or inter-current illnesses

Luchins DJ, Hanrahan P, Murphy K. Criteria for enrolling dementia patients in hospice. J Am Geriatr Soc 45:1054, 1997 .

predicting prognosis dementia patients in ltc
Predicting Prognosis: Dementia Patients in LTC

Risk Factors Identified from MDS

  • ADL score 28 Male
  • Congestive Heart Failure Cancer
  • Shortness of Breath Oxygen Therapy
  • < 25% of food eaten most meals Bedfast
  • Unstable Medical Condition Age > 83
  • Bowel Incontinence
  • Not awake most of day

Mitchell SL, et al. Estimating Prognosis for Nursing Home Residents with Advanced Dementia. JAMA 291:2734, 2004.

predicting prognosis dementia patients in ltc1
Predicting Prognosis: Dementia Patients in LTC

Risk of Death within 6 months based on “Risk Score”

  • 0 8.9%
  • 1-2 10.8%
  • 3-5 23.2%
  • 6-8 40.4%
  • 9-11 57.0%
  • > 12 70.0%

Mitchell SL, et al. Estimating Prognosis for Nursing Home Residents with Advanced Dementia. JAMA 291:2734, 2004.

end stage cerebrovascular disease
End Stage Cerebrovascular Disease

Acute End Stage CVA

Patient has one or more of the following at least 3 days after an acute stroke

  • Coma
  • Persistent Vegetative State
  • Severe obtundation with myoclonus
  • Postanoxic encephalopathy

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.

end stage cerebrovascular disease1
End Stage Cerebrovascular Disease

Acute End Stage CVA

Other factors associated with high mortality risk 3 days post-CVA

  • Abnormal brain stem response
  • Absent verbal response
  • Absent withdrawal response to pain
  • Serum creatinine > 1.5
  • Age > 70 years

Hamel MB, Goldman L, Teno J, et al: Identification of comatose patients at high risk for death or severe disability. JAMA 273:1842, 1995.

end stage cerebrovascular disease2
End Stage Cerebrovascular Disease

Chronic End Stage CVA

  • Coma, PVS, or Post-stroke or multi-infarct dementia consistent with FAST Stage 7
  • Patient has had one or more of the following in the last 6-12 months
    • Aspiration pneumonia
    • Pyelonephritis or upper urinary tract infection
    • Septicemia
    • Decubitus ulcers: Stage III or IV
    • Fever, recurrent, after antibiotics
    • Altered nutritional status

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.

adult failure to thrive debility
Adult Failure to Thrive-Debility
  • General Criteria
    • Declining Functional Status
    • Unintentional Weight Loss
      • > 10% ideal body weight
      • Decreasing Body Mass Index (BMI) < 22 kg/m2
      • Decreasing MMA
  • Multiple illnesses, with no single illness or diagnosis itself being terminal
  • Decision not to pursue further evaluation due to patient’s advanced age

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.

aids and hiv disease
AIDS and HIV Disease
  • RNA Viral Load
    • > 100,000 persistently
    • < 100,000
      • Refusing anti-retrovirals
      • Declining functional status
  • HIV related opportunistic illnesses
  • Other factors
    • Chronic persistent diarrhea
    • Substance abuse
    • Age > 50
    • Decision to forgo therapies
    • Symptomatic CHF

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.

other diagnoses
Other Diagnoses
  • ALS
    • Rapidly progressive disease
    • Impaired ventilatory capacity
    • Nutritional impairment
    • Comorbid conditions as in dementia
  • End-stage Renal Disease
    • Dialysis criteria in patient refusing or choosing to discontinue dialysis
  • End-stage Liver 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.

determining prognosis
Determining Prognosis
  • Clinical Judgment
  • Guidelines as an aid to Clinical Judgment
    • General Guidelines
      • Unintentional Weight loss
      • Declining Performance status
      • Increase use of healthcare services
      • Patient/family goals
    • Disease specific guidelines
determining prognosis1
Determining Prognosis

Would you be surprised if this patient were to die in the next six months?