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Palliative Care Perspectives : Chapter 2: Dying Trajectories and Prognostication : Prognosis, Palliative Care, and Hospice Eligibility

Prognosis is only one factor that needs to be considered in determining whether a patient would benefit from palliative or hospice care. Other factors to be considered are whether the system of care would best meet the patient's and family's needs and whether such care is in keeping with patient and family goals of care. Unfortunately, in the United States, influenced heavily by the Medicare Hospice Benefit, excessive weight has been given to life expectancy as a criterion for hospice eligibility. As originally formulated in the benefit, a patient is considered appropriate for hospice if he or she has a life expectancy of six months or less if the disease follows its natural course. As the discussion above reflects, this is easier to determine for some diseases, such as cancer, than for others.

Guidelines have been developed to help determine when hospice might be appropriate for patients with diseases other than cancer (and, by extension, when palliative care should also be considered). The evidence base for many of these guidelines is weak in terms of prognostic accuracy. Perhaps more important, the guidelines do not challenge more basic assumptions regarding the importance of prognosis in determining who might benefit from palliative or hospice care. For example, patients with dementia must be bedridden and virtually mute before hospice is considered "appropriate" in the United States. Speaking for myself, I will be ready for a hospice-palliative approach to care, stressing attention to quality of life and avoidance of acute care hospitals, long before I reach this level of debilitation. Patients sick enough to meet the criteria listed below are very sick indeed. They would likely benefit from consideration of palliative and hospice care in whatever form it is available.

Congestive Heart Failure: Class IV failure. Ejection fraction < 20%. Optimally treated, including afterload reduction. Two to three acute care admits for heart failure in the past year.

COPD: Oxygen dependent. Unresponsive to bronchodilators. Forced expiratory volume (FEV1) after bronchodilator less than 30% of predicted. At best able to walk only a few steps without tiring. Resting pCO2 > 50, O2 Sat off O2 < 88, pO2 < 55 on oxygen. Cor pulmonale, unintended weight loss > 10% of body weight, resting tachycardia > 100, two to three acute care admits for COPD in the past year.

Renal failure: Chronic renal failure with creatinine > 8.0, off dialysis.

Cirrhosis/liver failure: Spends most of time in bed, albumin < 2.5, INR > 1.5. At least one of the following co-morbidities: encephalopathy, history of spontaneous bacterial peritonitis, refractory ascites, recurrent variceal bleeding, hepatorenal syndrome.

Dementia: Largely mute, bed-bound, unable to ambulate without assistance. History of recurrent aspiration pneumonias. Progressive weight loss. At or beyond stage seven of the Functional Assessment Staging scale. Urinary and fecal incontinence. Presence of co-morbid conditions in the past year: aspiration pneumonia, pyelonephritis, sepsis, decubitus ulcers, fever after antibiotics, difficulty swallowing or eating food, unintended weight loss of >10% over last six months.

Strokes/coma: Acute phase: Coma or persistent vegetative state secondary to stroke beyond three day's duration. Coma with any four of the following on day three of coma: abnormal brain stem response, absent verbal response, absent withdrawal response to pain, serum creatinine > 1.5, age >70. Dysphagia severe enough to prevent a patient from receiving food and fluids who declines or is not a candidate for artificial nutrition and hydration.

Chronic phase: Clear-cut predictors have not been as well classified. Consider the following: poor functional status with Karnofsky score <50%, post-stroke dementia with Functional Assessment Staging System (FAST) score > 7, poor nutritional status whether on artifical nutrition or not, > 10% weight loss over past six months, serum albumin < 2.5. Recurrent medical complications such as aspiration pneumonia, pyelonephritis, sepsis, refractory stage three to four decubiti, recurrent fever following antibiotics.

(Adapted from Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, 2nd ed. National Hospice Organization, Arlington Va., 1996.)

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.