Prognostication

Question 1

What is the 6 month mortality risk after hip fracture for patients with dementia?

Answer 1

55% (vs 12% for patients who are cognitively intact)

Question 2

What is the 6 month mortality risk for patients with dementia who are hospitalized with pneumonia?

Answer 2

53% (vs 13% for patients who are cognitively intact)

Question 3

What score on Mortality Risk Index (Mitchell Index) is threshold for hospice eligibility?

Answer 3

Score of 9-11 equates to 57% risk of death at 6 months

Score of 12 or more is 70% risk of death at 6 months

Question 4

Populations where feeding tube placement can be considered? (4)

Answer 4

1) ALS- will improve survival
2) Strokes- may live longer
3) ENT cancer- especially if cancer is curative and may improve QOL
4) PVS- will live longer

Question 5

What is the median survival for patients with cancer and a PPS/KPS of 40-60?

Answer 5

1-3 month survival

Question 6

Median survival for patients with cancer and hypercalcemia?

Answer 6

6-8 weeks (unless breast, MM)

Question 7

Median survival for patients with cancer and leptomeningeal disease?

Answer 7

21 days

3 weeks

Question 8

What 4 factors influence prognosis (at 1 year mortality level) for patients on MV for 21 days?

Answer 8

For patient on MV FOR 21 DAYS
* Age >50
* Pressors
* Platelets < 150K
* Dialysis

Above Factors are Each 1 Point

0 of the above: 15% 1 year mortality
1 of the above: 42% 1 year mortality
2 of the above: 88% mortality (100% dependent in all ADLs)
3-4 of the above: > 95% 1 year mortality

Question 9

Median prognosis for patient with malignant pericardial effusion?

Answer 9

8-12 weeks

Question 10

Median prognosis for patients with cancer with MULTIPLE brain metastases?

Answer 10

Without XRT 4-8 weeks (1-2 months)

WITH XRT 12-24 weeks (3-4 months)

Single brain met with good performance status can have prognosis of short years (for patients with breast cancer or other less aggressive cancer types)

Treated brain mets- think PX more 6-8 months

Question 11

What 5 clinical signs or symptoms are most predictive of death within 12 hours?

Answer 11

1) Decreased UOP <100 cc/12hr
2) Pulseless radial artery
3) Cheyne-Stokes breathing
4) Mandibular breathing
5) Death rattle

Question 12

Four signs/factors associated with WORSE prognosis in ALS patients?

Overall prognosis after diagnosis?

Answer 12

1) Age > 70
2) Bulbar features
3) BMI < 25
4) FTD (present in 15-41%)

24-36 months, influenced by the ABOVE

Riluzole survival benefit- only 2-3 months

Question 13

What is the discerning factor between a COMA and PVS? PVS and MCS?

Answer 13

Patient in PVS will have sleep-wake cycles, patients in coma do NOT

Patient in Minimally Conscious State will have SOME (though minimal) purposeful movement/interaction with environment while PVS will not

Question 14

What is the average survival for patients after terminal removal of MV?

Answer 14

Median time to death is 0.9 hours

Half die within 1 hour

Vast majority DIE WITHIN 10 HOURS

Question 15

What is the mean life expectancy of patients with advanced heart failure on infusion of inotropes (via PICC/central line)?

Answer 15

Mean life expectancy is 9 months

25% survive to 1 year

Question 16

For patients with ALS and who have PEG placement, what is their average prognosis?

Answer 16

For URGENT PEG placement, survival of about 6 months (longer prognosis if PEG placed in non urgent setting)

Placement of PEG should occur when FVC >50%

Question 17

What is the prognosis for patients with advanced cancer and malignant pleural effusion or malignant bowel obstruction?

Answer 17

< 6 month

Question 18

How long will someone live after cessation of eating and drinking?

Answer 18

After discontinuation of food and fluid, patients often survive 1 to 3 weeks

VARIES depending on underlying etiology

Question 19

What predicts poorer prognosis in patients with NYHA Class IV? (9)

Answer 19

1) Na < 136 mEg/L indicates poor
2) Recent cardiac hospitalization
3) Systolic blood pressure <100 mmHg and/or pulse faster than 100 bpm
4) Decreased left ventricular ejection fraction
5) Treatment-resistant ventricular dysrhythmias
6) Anemia
7) Cachexia
8) Reduced functional capacity
9) Comorbidities (diabetes, depression, chronic obstructive pulmonary disease [COPD], cirrhosis, cerebrovascular disease, cancer, and HIV-associated cardiomyopathy

NYHA Class IV has 60-70% chance of surviving 1 year

NYHA Class IV ~ ECOG 3 or PPS 60%

Question 20

Brain Death Criteria for ADULTS

Answer 20

1) absent of brainstem reflexes
2) the presence of coma
3) positive apnea test, meaning that the patient had the appropriate rise in serum PCO2 and lack of initiation of spontaneous respiration for the specified time period of 10 minutes
4) prerequisite criteria for core temperature (>32C), drug or electrolyte abnormalities that could confound the clinical assessment have been excluded.

Needs 2 separate clinical exams (can be same doctor, unlike in pediatric patients)

Question 21

What is overall 1 month prognosis for patients with intracerebral hemorrhage?

What is the chance of meaningful recovery at 6 months?

Answer 21

52% 1 month mortality

90% 1 month mortality if a brainstem bleed

Among survivors, there is only a 20% chance of meaningful function by 6 months.

• elderly
• poor neurological condition on arrival
• size of ICH (> 60 cc, > 90% 1 month mortality)
• bleed involving ventricles
• bleed expansion w/in 24 hours

Question 22

KPS score of what or lower is associated with < 6 months survival in patients with advanced cancer?

Answer 22

KPS/PPS of 50 or less

Question 23

What is the effect of hip fracture in patients with cancer in regards to mortality?

Answer 23

Hip fracture DOUBLES the mortality risk within the first year for patients w/ cancer

Risk if highest in first 3-6 months
Mortality risk INCREASED for 6 years following fracture

Hip fracture responsible for death in 1 of 5 affected older adults

Question 24

What % of patients survive to discharge after in hospital code? What predicts lower success rate?(6)

Answer 24

15%, or 1 in 6 patients, who undergo CPR in the hospital may survive to dischare

1) Dementia
2) Cr > 1.5
3) AA race
4) Metastatic cancer
5) Sepsis day prior
6) Dependence in ADLs

Question 25

LMAC of 22.5 correlates to WHAT BMI?

Answer 25

18.5

Question 26

Palliative Prognostic Score (aka PaP) predicts survival at what time point?

Answer 26

30 day mortality Includes KPS, WBC, lymphocytes, clinical prediction of LE, anorexia, dyspnea

Question 27

Palliative Prognostic Index predicts survival at what time point?

Answer 27

Looks at 3 and 6 week mortality Includes PPS, oral intake, dyspnea, delirium, edema in CANCER patients

Question 28

At what MELD score would you admit to hospice?

Answer 28

> 20

Question 29

What is 90 day mortality for ischemic stroke? What 3 things increase mortality rate?

Answer 29

17-21% 1 of 5 die within 3 months 1) Medical complications while in hospital 2) Older age 3) NIHHS score (HIGH score is BAD)- STRONGEST predictor- measured at 24 H

Question 30

Overall 30 day mortality following TBI? 5 factors associated with worse prognosis?

Answer 30

20% with highest mortality associated with worst initial GCS scores (< 8 is coma) With initial GCS 3-4, only 20% survive HALF of thee patients have a "good outcome" (GOS 4-5) - Older age - Lower initial GCS - Abnormal initial pupillary reaction - Longer length of coma - Duration of post trauma amnesia All the above associated with WORSE outcome -Favorable outcome (GOS 4-5) likely when the time to follow commands is less than 2 weeks after injury, and the duration of post-traumatic amnesia is less than 2 months. -Poor outcome (GOS <4) is likely when the patient is > 65 years old, the time to follow commands is longer than 1 month, or the duration of post-traumatic amnesia is greater than 3 months. -Notably, 10% of patients will not have the outcome predicted by the guidelines above

Question 31

Median survival for patients who do NOT regain ambulatory ability after TX for SCC? Median survival for patients who DO regain ambulatory ability after TX for SCC?

Answer 31

Median survival is 76 days! 1-2 months 33% of these patients eventually go home without assistance but over 2/3rds never regained ambulatory ability For patients who DO regain ambulatory ability- prognosis is 7-9 months

Question 32

Prognosis with multiple brain mets and very good PPS (with disease like breast cancer)?

Answer 32

7-12 months Patients with brain metastases who are younger, have a good functional status, and good primary disease control have a median survival of > 6 months. Whole brain radiotherapy has been shown to improve median survival and neurologic symptoms and should be considered as part of a palliative treatment plan.

Question 33

Four very POOR prognostic signs for comatose survivors after cardiac arrest?

Answer 33

1) presence of myoclonus status epilepticus at 24 hours in patients with primary circulatory arrest 2) absence of pupillary responses at 72 hours after CPR 3) absent corneal reflexes at 72 hours after CPR 4) absent or extensor motor responses at 72 hours after CPR.

Question 34

Prognostication for stroke patients related to dysphagia?

Answer 34

Dysphagia is a common occurrence after stroke (~65% of stroke patients), with half of those with dysphagia improving within 2 weeks and 15% with continued dysphagia at 30 days. Only 8% of acute stroke patients require enteral feeding 6 months after acute ischemic CVA

Question 35

Prognosis for patients after SCT who have septic shock/ICU level care?

Answer 35

In one multicenter retrospective study of 209 allogeneic stem-cell-transplant patients, those who required mechanical ventilation had in-hospital, 6-month, and 1-year survival rates of 15.6%, 14%, and 10.6%, respectively. Of these patients, those who were admitted to the ICU after the 30-day engraftment period had in-hospital, 6-month, and 1-year survival rates of 11.8%, 9.2%, and 6.5%, respectively HOWEVER- subsets of patients with median survivals of 3 to 5 years after second transplant for whom a trial of aggressive therapy for post-transplant complications may be worth considering.

Question 36

Impact of chemotherapy (docetaxel) for patients with hormone refractory prostate cancer?

Answer 36

- significant improvement in overall survival (the increase in length of survival was < than 2.5 months) - found to reduce bone pain and PSA levels - improved quality of life - median OS of 2-5 months

Question 37

Prognosis for patients with HRS type 1? HRS type 2?

Answer 37

1) HRS Type 1: days to weeks (usually 1-2 months) (if not responsive to fluids/TX) 2) HRS Type 2: mean survival is typically 6 to 8 months

Question 38

Prognosis for patients with PAH on IV Flolan? Impact of drug?

Answer 38

> 6 months the addition of intravenous epoprostenol (Flolan) has been shown in small clinical trials to improve function, symptoms, and survival rates, even in patients who fail to respond to appropriate treatments.

Question 39

3 biggest predictors of POOR neurological outcome after cardiac arrest?

Answer 39

Bilateral absence of pupillary reflexes more than 24 hours after return of spontaneous circulation, bilateral absence of corneal reflexes more than 24 hours, and bilateral absence of somatosensory-evoked potentials between days 1 and 7 all indicate poor neurologic outcome

Question 40

Survival for patients with initial GCS of 3-5?

Answer 40

15-20%

Question 41

One year mortality rate after development of hepatic encephalopathy?

Answer 41

60%