Prognostication Oxford Flashcards
Why is prognostication important?
- provides patients with important information to set goals, priorities
- technical information for many clinical decisions (eligibility for surgery, treatment etc)
- Eligbility for Compassionate EI, admission to hospice, certain drug coverage plans (pall blue cross)
- Important for design and analysis of clinical trials
What problems do professionals have in discussing prognosis?
- Avoidance
- wait to be asked, not volunteer
- Optimism
- Vague
- Do not use for treatment decision making
List Three components of prognostication
- Formulating/ determining prognosis
- Communication prognosis
- Using it for clinical decisions
Step 1: Formulation of prognosis
- Clinical prediction
- subjective
- semi structured with median survival adjusted for indiv factors
- Actuarial judgment
- medial survival, hazard ratio
- performance status PPS, ECOG
PPS and prognosis
- more rapid decline in last month of life
- 30% = 3 months
- rate of decline most predictive
What factors are predictive and non-predictive of correlation with survival?
Predictive (associated with shorter prognosis)
- self rated health
- poor mood
- dyspnea
- confusion
- anorexia/cachexia
- comorbidities
Not predictive (not associated with shorter prognosis)
- Pain
- QOL scores
Palliative Prognostic Index
- PPS, po intake, dyspnea, delirium edema
- PPI > 4 predicts death within 6 weeks
- PPV 83%, NPV 71%
Prognosis in CHF
- prognosis worse than many cancers
- NYHA IV : 1 year mortality 30-40%
- high incidence sudden death difficult for mid range predictors
- disease trajectory
NYHA
1 - cardiac disease, aysmptomatic
2 - mild sx, sligh limitation
3 - significant limitation, comfortable only at rest
4 - severe limitation, sx at rest
Prognosis for survival to discharge after CPR
- in hospital cardiac arrest, ROSC 50%,
- but survival to discharge 20%
Prognosis in COPD
- age
- FEV1
- BMI < 21
- chronic hyper cap
- CV disease
- peformance status poor
- recent hospitalizations
- dyspnea
- illness trajectory makes prognositication difficult
- short term and long term prognosis
- BODE
- BMI
- Obstruction
- Dyspnea
- Exercise capacity
Prognosis in Alzheimer’s Dementia
- predictable decline
- inability to walk unaided = final phase of illness
- long prognosis
Step 2: Communication of Prognosis
- physicians overestimate prognosis
- patients are diverse in what they want for info
- facilitate hope
- be honest, but not blunt
- pace information sharing to match patient desires
- explore realitic goals
Approach to sharing prognosis
Clarify what information is wanted.
Use a prognostic tool to estimate median survival and adjust for indivudal circumstances
Explain median survival (50% live longer, 50% live shorter)
Explain typical survival, best case scenario, worse case scenario
Language for sharing prognosis
- Hours to days
- Days to short weeks
- Weeks to short months
- Long months - a year
