Deciding When Hospice is Needed for Patients with Advanced Cancer

1
Deciding When Hospice is Needed for Patients
with Advanced Cancer Non-malignant Diagnoses

• Barry M. Kinzbrunner, MD

2
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) Harrisons
  Principles and Practice of Medicine, 9th edition.
  New York McGraw Hill, 1980.

3
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.

4
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 physicians or medical directors clinical
  judgement regarding the normal course of the
  individuals illness.

5
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.

6
General Guidelines

• Changes in Functional Status
• Cancer Patients
• PPS lt 50 or ECOG gt 3
• PPS lt 60 or ECOG gt 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 lt 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.

7
Palliative Performance Scale (PPS)
8
General Guidelines

• Unintentional Weight Loss
• gt 10 of normal body weight
• Declining Body Mass Index (BMI)
• lt 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.

9
General Guidelines

• Intangible Factors
• Patients 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.

10
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.

11
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.

12
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
• Hodgkins 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.

13
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.

14
Cancer Category 2

• Treatable, high probability remission
• Adult acute myeloblastic and acute lymphoblastic
  leukemias
• Intermediate and high-grade non-Hodgkins
  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.

15
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.

16
Cancer Category 3

• Treatable, incurable with favorable prognosis
• Prostate carcinoma
• Breast carcinoma
• Chronic lymphocytic leukemia
• Chronic myelocytic leukemia and
  myeloproliferative disorders
• Low-grade non-Hodgkins 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.

17
Cancer Category 4

• Characteristics
• Stage IV or advanced metastatic disease
• Incurable
• Responses to chemotherapy in lt 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 lt 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.

18
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.

19
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.

20
Cancer Category 5

• Characteristics
• Stage IV or advanced metastatic disease
• Incurable
• Generally considered unresponsive or very poorly
  responsive (lt 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.

21
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.

22
End-stage Cardiac Disease

• Dyspnea and/or chest pain at rest or with
  minimal exertion (NYHA Class IV)
• Ejection Fraction lt 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.

23
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.

24
End-stage Pulmonary Disease

• Disabling dyspnea as demonstrated by
• Dyspnea at rest or with minimal exertion
• Dyspnea poorly responsive to bronchodilators
• FEV-1 lt 30 predicted, post-bronchodilator
• Progressive pulmonary disease as manifested by
• Multiple hospitalizations, ER visits, or doctors
  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.

25
End-stage Pulmonary Disease

• Other indicators of a poor prognosis
• Body weight
• lt 90 ideal body weight or
• gt 10 weight loss
• Resting tachycardia gt 100/min
• Abnormal ABGs or O2 saturation
• pO2 lt 55 mm Hg
• O2 saturation lt 88
• pCO2 gt 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.

26
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.

27
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.

28
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 gt 10 of normal body weight
• Decreasing Body Mass Index (BMI) lt 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.

29
Prognostic Accuracy of Dementia Guidelines

• FAST 7-C
• Median survival of lt 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 lt 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 451054, 1997 .

30
Predicting Prognosis Dementia Patients in LTC

• Risk Factors Identified from MDS
• ADL score 28 Male
• Congestive Heart Failure Cancer
• Shortness of Breath Oxygen Therapy
• lt 25 of food eaten most meals Bedfast
• Unstable Medical Condition Age gt 83
• Bowel Incontinence
• Not awake most of day
• Mitchell SL, et al. Estimating Prognosis for
  Nursing Home Residents with Advanced Dementia.
  JAMA 2912734, 2004.

31
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
• gt 12 70.0
• Mitchell SL, et al. Estimating Prognosis for
  Nursing Home Residents with Advanced Dementia.
  JAMA 2912734, 2004.

32
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.

33
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 gt 1.5
• Age gt 70 years
• Hamel MB, Goldman L, Teno J, et al
  Identification of comatose patients at high risk
  for death or severe disability. JAMA 2731842,
  1995.

34
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.

35
Adult Failure to Thrive-Debility

• General Criteria
• Declining Functional Status
• Unintentional Weight Loss
• gt 10 ideal body weight
• Decreasing Body Mass Index (BMI) lt 22 kg/m2
• Decreasing MMA
• Multiple illnesses, with no single illness or
  diagnosis itself being terminal
• Decision not to pursue further evaluation due to
  patients 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.

36
AIDS and HIV Disease

• RNA Viral Load
• gt 100,000 persistently
• lt 100,000
• Refusing anti-retrovirals
• Declining functional status
• HIV related opportunistic illnesses
• Other factors
• Chronic persistent diarrhea
• Substance abuse
• Age gt 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.

37
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.

38
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

39
Determining Prognosis

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