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Determining Prognosis in Cancer and Non-Cancer Diagnoses

This document outlines a continuing education program for healthcare professionals focused on determining prognosis in cancer and non-cancer diagnoses to support hospice eligibility. It details course requirements, accreditation, and credit designations, as well as the importance of understanding patient trajectories in end-of-life care. Objectives include identifying prognostic indicators and understanding the Medicare hospice benefit, with an emphasis on clinical judgment and specific patient factors such as physical function and weight changes.

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Determining Prognosis in Cancer and Non-Cancer Diagnoses
Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CME Provider Information
CE Provider Information VITAS® Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS® Healthcare programs in California/Connecticut/Delaware/ Illinois/Northern/Virginia/Ohio/Pennsylvania/Washington DC/ Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/2021-06/06/2024). Social Workers participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers completing this course receive 1.0 continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2025. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
Goal The goal of this presentation is to help healthcare professionals identify when patients are entering the end stages of cancer and non-cancer diagnoses that support hospice eligibility.
Objectives • Appreciate the role of determining a patient’s prognosis • Define the Medicare Hospice Benefit, including eligibility requirements • Understand the theoretical trajectories of dying • Recognize six general domains of decline that support poor prognosis and clinical progression of disease • Describe disease-specific factors that help determine prognosis in patients with cancer and non-cancer diagnoses
“Medicine is a science of uncertainty and an art of probability.” —Sir William Osler "Father of Modern Medicine"
Prognosis and Practice of Medicine • What to expect from an individual’s disease course • Clinicians’ prognostic estimates are a framework to make informed decisions about care – Health screening – Disability outcomes – Disease management – Advance care planning – End-of-life decisions, including hospice enrollment
Medicare Hospice Benefit Medicare Benefit Policy Manual (Rev. 246, 09-14-18). Terminal illness: “A medical prognosis (of a) life expectancy of 6 months or less, as determined by 2 physicians, if the illness runs its normal course.”
Medicare Hospice Benefit (cont.) Benefits Protection and Improvement Act (BIPA) of 2000 Certification of terminal illness of an individual who elects hospice “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”
Predicting Prognosis Christakis, N., et al. (2000). Extent and determination of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320:269. • 20% of the doctors’ predictions were accurate, 63% were over-optimistic, and 17% over pessimistic • Greater experience = better prediction accuracy • Longer relationship with a clinician = worse prediction accuracy A recent study found palliative clinicians overestimate survival by 85%, leading to less hospice use and shorter stays.
Lunney, J., et al. (2003). Patterns of functional decline at the end of life. JAMA, 289:2387-2392. Lunney, J., et al. (2018). Mobility trajectories at the end of life: Comparing clinical conditions and latent class approaches. Journal of the American Geriatric Society, 8;66: 503-508. Theoretical Trajectories of Dying Dependence on ADLs Prior to Death 1 year 1 month Terminal Illness 0.77 4.09 Organ Failure 2.10 3.66 Frailty 2.92 5.84
General Domains to Consider • Clinical judgment • Nutrition • Physical function • Cognition • Healthcare utilization • Symptoms
Clinical Judgment • Would you be surprised if this patient were to die in the next year?
Surprise Question Downar, J., et al. (2017). The "surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. CMAJ, 189(13):E484-E493. • Would you be surprised if this patient were to die in the next year? • Recent meta-analysis – Sensitivity – Specificity – PPV – NPV – AUC 67.0% (55.7%–76.7%) 80.2% (73.3%–85.6%) 37.1% (30.2%–44.6%) 93.1% (91.0%–94.8%) 0.81 (95% CI 0.78–0.86)
Nutritional Status • Weight change – ≥ 10% of normal body weight in 6 months – ≥ 5% of normal body weight in 1 month • BMI change (BMI < 22) • Albumin level • Choking and/or pocketing food • Wounds • Muscle wasting – Sarcopenia – Temporal wasting
Long-Term Care 153 residents • 24 lost 5% weight in 1 month • 5.1 times more likely to die in 1 year Outpatient Prospective evaluation of 91 patients with weight loss • 35% no identifiable cause • 25% died over the ensuing year Weight Loss and Prognosis Ryan, C., et al. (1995). Unintentional weight loss in long term care: Predictor of mortality in the elderly. Southern Medical Journal, 88(7):721-724. Marton, K., et aI. (1981). Involuntary weight loss: Diagnostic and prognostic significance. Annals of Internal Medicine, (5):568-74.
Cabre, M., et al. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing, 39:39-45. Dysphagia and Survival Mortality with dysphagia: 30-day: 22.9% 1-year: 55.4%
Malnutrition The criterion in only one of the columns needs to be achieved in order to qualify for that type of malnutrition. Type of Malnutrition % of Normal Weight BMI Serum Albumin* Normal: No Malnutrition 90-100 19-24 3.5-5.0 Mild 85-89 18-18.9 3.1-3.4 Moderate 75-84 16-17.9 2.4-3.0 Severe < 75 < 16 < 2.4
Physical Function Palliative Performance Scale (PPS) • Scale of 0% (dead) to 100% (normal) • Activities of daily living – Bathing – Continence – Dressing – Transferring – Ambulation – Eating • Homebound status • Taking to bed • Falls
Anderson, F., et al. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1):5-11. Mobility IADLs ADLs % Ambulation Activity and Evidence of Disease Self-Care Intake Level of Consciousness 100 Full Normal Activity Full Normal Full No Evidence of Disease 90 Full Normal Activity Full Normal Full Some Evidence of Disease 80 Full Normal Activity With Effort Full Normal or Reduced Full Some Evidence of Disease 70 Reduced Unable to Do Normal Job/Work Full Normal or Reduced Full Some Evidence of Disease 60 Reduced Unable to Do Hobby/Housework Occasional Assistance Necessary Normal or Reduced Full or Confusion Significant Disease 50 Mainly Sit/Lie Unable to Do Any Work Considerable Assistance Required Normal or Reduced Full or Confusion Extensive Disease 40 Mainly in Bed As Above Mainly Assistance Normal or Reduced Full or Drowsy or Confusion 30 Totally Bed Bound As Above Total Care Reduced Full or Drowsy or Confusion 20 As Above As Above Total Care Minimal Sips Full or Drowsy or Confusion 10 As Above As Above Total Care Mouth Care Only Drowsy or Coma 0 Death -- -- -- -- Based on what the patient can do! Generally Hospice Eligible Palliative Performance Scale
Survival by PPS at Acute-Care Hospital Olajide, O., et al. (2007). Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine, 10(1):111-7.
ADL Difficulty Proportion Population Median Survival None 72.1% 10.6 yrs Mild 16.1% 6.5 yrs Moderate 7.0% 5.1 yrs Severe 4.3% 3.8 yrs Complete 0.5% 1.6 yrs Activities of Daily Living: Difficulty and Death Stineman, M., et al. (2012). All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage. Journal of the American Geriatric Society, 60(3):485-92.
Homebound Status and 2-Year Mortality Soones, T., et al. (2017). Two-year mortality in homebound older adults: An analysis of the National Health and Aging Trends Study. Journal of American Geriatric Society, 65:123–129. Homebound 12.1% Improved and no longer homebound 26.9% Still homebound 14.9% Semi-homebound 5.8% Nursing home 40.3% Died
Taking to Bed and Prognosis Gill, T., et al. (2019). Taking to bed at the end of life. JAGS, 67(6), 1248–1252. Bed rest increases as death approaches: • 24 months before death: 12.4% • 5 months before death: 19.0% • 1 month before death: 51.6% The number of days of bed rest increases as death approaches: • 4 months before death: 7 days of bed rest • 1 month before death: 14 days of bed rest Almost 90% take to bed prior to death, and number of days in bed increases.
25% of those who fell died within 1 year. Falls and One-Year Mortality Wild, D. (1981). How dangerous are falls in old people at home? British Medical Journal (Clinical Research Edition), 282(6260): 266–268. Cause Fallers Controls Cerebral vascular accident 7 2 Bronchopneumonia 12 3 Carcinoma 3 1 Congestive cardiac failure 5 1 Myocardial infarction 5 1 Total 32 8 4 0 0 1 2 3 4 5 6 7 8 9 10 11 12 8 24 20 16 12 28 32 Number of Deaths Months After Index Fall Cumulative mortality in 125 fallers and 125 controls in 12 months after index fall. Fallers Controls
Cognitive Decline • Orientation to person, place, and time • State of consciousness: Awake or asleep in 24 hours • Ability to communicate and follow commands • Ability to recognize environment
Cognition and Survival Neale, R., et al. (2001). Cognition and survival: An exploration of a large multicenter study of a population aged 65 years and older International. International Journal of Epidemiology, 30:1383-1388.
Increased Healthcare Utilization • Clinic visits • Subspecialty visits • Emergency department visits • Hospitalizations
Hospitalization, ADL Change, and Death Boyd, C., et al. (2008). Recovery in activities of daily living among older adults following hospitalization for acute medical illness. Journal of the American Geriatric Society, 56(12): 2171-2179. 83.8% 33.5% 80.0% 37.4% 73.7% 36.5% 67.0% 30.1% 13.5% 53.0% 12.9% 40.2% 14.9% 32.4% 15.2% 28.6% 2.7% 13.5% 7.1% 22.4% 11.4% 31.2% 17.8% 41.3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Discharged at baseline function Discharged with a new or additional disability in ADL Discharged at baseline function Discharged with a new or additional disability in ADL Discharged at baseline function Discharged with a new or additional disability in ADL Discharged at baseline function Discharged with a new or additional disability in ADL Baseline Decline Death 1 month 3 months 6 months 12 months
Uncontrolled Symptoms • Pain • Shortness of breath • Delirium • Agitation • Nausea and vomiting • Constipation • Exhaustion, fatigue, low activity
Acute Neuropsychological Symptoms and Mortality Zippirich, H., et al. (2020). Outcome of older patients with acute neuropsychological symptoms not fulfilling criteria of delirium. JAGS, 68:1469-1475. Changes in mental status that may prompt an evaluation of delirium Confusion Assessment Method (CAM) Features of Delirium: 1. Acute onset of changes or fluctuation in mental status 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness • Delirium is diagnosed when features 1 and 2, plus either feature 3 or 4, are present • Exhibiting only 2 of the 4 CAM features indicates symptoms of delirium 37.7 44.3 36.1 41.8
Indicators of Poor Prognosis in Cancer and Non-Cancer Diagnoses
Cancer Trajectory Christakis, N., et al. (2000). Extent and determinants of error in doctors’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320(7233):469-72. Mackillop, W., et al. (1997). Measuring the accuracy of prognostic judgements in oncology. Journal of Clinical Epidemiology, 50:21-29. Function Death is more predictable Low Onset of illness Decline usually 3-6 month Slower trajectory for hormone-sensitive tumors, i.e., breast, prostate High Functional Status: Key Determinant Prognosis ECOG 3: 50% of time in bed or chair; hospice eligible
ECOG 0: Fully active, able to carry on all pre-disease performance without restriction. 1: Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature. 2: Ambulatory. Able to self-care. Unable to carry out work activities. 3: Limited self-care. Confined to bed/chair > 50%. 4: Disabled. Unable to self-care. Totally confined to bed/chair. 5: Dead. Jang, R., et al. (2014). Simple prognostic model for patients with advanced cancer based on performance status. American Society of Clinical Oncology. Cancer, Function, and Prognosis
Cancer Prognosis: Helpful Numbers Palliative Care Network of Wisconsin. (2015, May). Fast Fact Number 13. Retrieved from: https://www.mypcnow.org/blank-hh45g Cancer Syndrome Estimated Survival Malignant hypercalcemia 8 weeks (except newly diagnosed breast or MM) Malignant pericardial effusion 8 weeks Carcinomatous meningitis 8-12 weeks Multiple brain metastases 1-2 months no XRT; 3-6 months with XRT Malignant ascites Less than 6 months Malignant pleural effusion Less than 6 months Malignant bowel obstruction Less than 6 months
Heart Failure Trajectory Lynn, J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health. Function Low NYHA Class III/IV Hospice Eligible NL and low EF maintain a similar trajectory and prognosis High Death NYHA Symptoms: Shortness of breath • Fatigue Chest pain • Palpitations Multiple Hospitalizations Death After Exacerbation
Median Survival in Heart Failure (HF) Patients by Age1 1 Shah, K., et al. (2017). Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology, 70.20: 2476-2486. 2Kheirbek, R., et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740. Hospitalization for HF is associated with a poor long-term prognosis and an elevated risk of cardiovascular (CV) and HF admission, irrespective of ejection fraction (EF). • Across all age groups, patients with HF (regardless of EF) had a markedly lower median survival than the life expectancy of individuals in the US • The median survival for patients with HF was similar by EF group but declined with advancing age • Factors associated with an even poorer prognosis include NYHA Class, hospitalization, weight loss, O2 use, renal insufficiency, anemia 18.7 15.1 11.9 9.1 6.8 5 3.6 2.9 2.3 1.7 1.2 0.8 3.3 2.8 2.6 1.8 1.3 1 4 3.4 2.6 2.2 1.5 0.9 0 5 10 15 20 65-69 70-74 75-79 80-84 85-89 ≥90 Median Survival in Years Ages in Years Median Survival Stratified by Age Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients Only 1 in 10 patients with advanced heart failure is referred to hospice2
HF and Prognosis Prognosis Tool Components Comments NYHA Class 1-year mortality listed I N/A II.7% III.13% IV.40-60% Patients can move among classes based upon response treatment Cachexia 7.5% weight loss 29% die 6 months 42% die 18 months Dry weight; independent age, NYHA, and EF Seattle Heart Failure Age, gender, NYHA Class, EF, BP, laboratory data, medications, and presence of devices. Predictors survival: NYHA class, EF, Na, SBP, ischemic etiology Predicts mean, 1-, 2-, and 5-year survival; overestimates at patient level; Based upon reduced EF mostly Surprise Question in HF Would you be surprised if this patient died within next year? Sensitivity 85%, NPV 88% Specificity 59%PPV 52%
Functional Status Predicts Hospice Eligibility in Cardiac Patients Creber, R., et al., (2019). Use of the palliative performance scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378. Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible. PPS Score Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level 60 Reduced Unable to do hobby/housework Occasional assistance Significant disease necessary Full or 50 Mainly sit/lie Unable to do any housework Extensive disease Considerable assistance required Normal or confusion 40 Mainly in bed Unable to do most activities Extensive disease Mainly assistance reduced Full or drowsy 30 Totally bedbound Unable to do any activities Extensive disease Requires total care +/- confusion
Advance Cardiac Hospice Eligibility Guidelines Patient is: • Optimally treated • Not a candidate/pursuing surgical options Symptoms include: • Fatigue • Dyspnea • Angina • Palpitations NYHA Class III: • Symptoms during less-than-ordinary activity • Significant comorbidities NYHA Class IV: • Symptoms at rest • Physical activity causes further discomfort Or Functional status and symptom burden are strongest indicators of hospice eligibility Significant Comorbidities with Poor Prognosis • Uncontrolled hypertension/hypotension • Uncontrolled diabetes with complications • Coronary artery disease • Prior MI or syncope • Renal dysfunction or CKD • Valvular heart disease • Frailty • Cognitive impairment • Malnutrition, cachexia • Ventricular arrhythmias • Older age at diagnosis • Lab/imaging abnormalities: hyponatremia, elevated BNP, or NT-proBNP • Dependence on inotropes
COPD Trajectory Fox, E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA, 282(17):1638–1645. Function Death Low High Multiple Hospitalizations Death After Exacerbation COPD patients often expire surrounding hospital Ongoing Lung Function Decline Despite Treatment, Accompanied by Hospitalizations and Progressive Dyspnea Hospice Eligible
COPD and Prognosis Fox, E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. JAMA, 282(17):1638-45. Almagro, P., et al. (2017). Palliative care and prognosis in COPD: A systematic review with a validation cohort. International Journal of COPD, 12:1721-1729. Prognosis of 6 months or less, 2 of 4 criteria • PaCO2 > 45 mmHg • Cor pulmonale • FEV-1 < 0.75 L • Episode of respiratory failure last 12 months
Lung Disease Hospice Eligibility Guidelines Disabling dyspnea as demonstrated by: • Dyspnea at rest or with minimal exertion while on oxygen therapy • Dyspnea unresponsive or poorly responsive to bronchodilators Progressive pulmonary disease manifested by one or more of the following: • Hospitalizations, ER visits, or doctor’s office visits • Frequent episodes of bronchitis or pneumonia • Frequent infections or respiratory failure requiring intubation • Cor pulmonale Supportive Features (ANY) • Unintentional weight loss of > 10% body weight over last 6 months • Resting tachycardia > 100/minute • Progressive inability to independently perform various activities of daily living (ADLs) • Abnormal tests (if available, but not necessary): – pO2 < 55 mmHg – pCO2 > 50 mmHg – O2 saturation < 88% on RA – FEV-1 < 30% predicted, post-bronchodilator And
CAGR=5.45%, P=.029 CAGR=13.12%, P<.001 CAGR=11.95%, P<.001 CAGR=7.69%, P=.009 CAGR=11.99%, P<.001 COPD and Over-Medicalized Hospital Deaths: 2010 to 2014 Shen, J., et al. (2018). Life sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014. Journal of Palliative Care, 33(3):159-166. The use of ventilation, vasopressors, dialysis, and CPR all increased significantly for COPD patients who died in the hospital from 2010 to 2014. 48.9% of COPD patients who died in the hospital had at least one life-sustaining treatment, with 25% receiving multiple treatments. Compounded Annual Growth Rates by Life-Sustaining Treatment for COPD Patients with Hospital Deaths
Dementia Trajectory Lynn, J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health. Function Death Low ADL Dependency Slow decline High Functional Dependency and Disease-Related Complication Hospice-Eligible Dependence in 3/6 ADLs (bathing, dressing, feeding, continence, ambulation, transferring) Disease-related complication within last 6 months
Wright, J., et al. (2011). End-of-life care: A practical guide. New York: McGraw Hill, p. 19. • Pneumonia • Pyelonephritis or upper urinary tract infection • Septicemia • 2 or more pressure ulcers: Stage III or IV • Febrile episodes • Altered nutritional status (weight loss 10% in 6 mo or 5% in 1 mo) • Eating difficulty, including feeding tube decision • Frequent falls or fall with fracture Patient experienced one or more of the following complications in the last 6 months: Dementias and Other End-Stage Neurodegenerative Disorders • Hip fracture, with or without repair • Delirium
Mitchell, S., et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361:1529-1538. • Median survival was 478 days, 24.7% within 6 months • 54.8% died, 93.8% in NH 6-month mortality 38.6% 6-month mortality 44.5% 6-month mortality 46.7% Natural History of Dementia
Morrison, R., et al. (2000). Survival in end-stage dementia following acute illness. JAMA, 284(1):47-52. Hip Fracture If impaired 55% Survival After Acute Illness: Severe Dementia vs. Cognitively Intact 6-month mortality If intact 12% Pneumonia If impaired 53% 6-month mortality If intact 13%
1-Year Survival From Baseline by FT Status Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival? JAGS, 60(10):1918–1921.
Teno, J., et al. (2013). Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA, 310(3). Two or More Hospitalizations of Nursing Home Residents With Dementia in One Year
Dementia Hospice Eligibility Guidelines Alzheimer’s Disease Lose ability to speak or communicate meaningfully (FAST 7A) Non-Alzheimer’s Disease or Mixed Dress • Incontinence of bowel and bladder Transferring • Ambulation • Eating • Bathing Plus have either A comorbidity resulting in structural/functional impairment: • Heart Disease (e.g., Heart Failure, Advanced Cardiac Disease, etc.) • Advanced Lung Disease (COPD) Or A clinical complication indicative of disease progression: • Febrile episode • Infection requiring antibiotics (aspiration pneumonia, UTI, sepsis) • Eating difficulty including dysphagia • Delirium • Feeding tube decision • Pressure ulcers • Dehydration requiring hospitalization • Weight loss (10% in 6 mo or 5% in 1 mo) • Frequent falls/fall with fracture
End-Stage Liver Disease Trajectory Natural History of Liver Disease Function Death Low Few Symptoms Many Symptoms High Three Hospitalizations last year of life Decompensated cirrhosis + hospitalization- jaundice, ascites, hepatic encephalopathy, and/or variceal hemorrhage 30% one-month readmit rate; one-month hospital last year life; 70% Die in ICU Etiology liver disease: ETOH (45%), Hep C (41%), NASH (26%) Symptoms of Decompensated Cirrhosis • Muscle cramps, 64% • Poor-quality sleep, 63% • Pruritus, 39% • Sexual dysfunction, 53% • Depression, >50% • Anxiety, >50% • Anorexia, >50% • Fatigue, >50%
Evidence-Based Disease Management Tapper, et al. (2023). "Diagnosis and Management of Cirrhosis and Its Complications: A Review." JAMA 329.(18):1589-1602. Median survival rates: • Variceal bleed: 17.7% 6-wk death • Ascites: 1.1 y • SBP 11%/y: 11 weeks • HRS 8%/y : < 2 weeks • HE: 0.95 y ≥ 65 and 2.5 y (<65) • HE: 0.95 y ≥ 65 & 2.5 y (<65) • HCC: 1-4% per/yr 5-yr survival 20%
ESLD and Hospice Eligibility 1 and 2 must be met 1. The patient should show both an INR>1.5 and a serum albumin <2.5 gm/dl 2. End-stage liver is present, and patient shows at least one of the following: • Ascites, refractory to treatment or patient non-compliant • Spontaneous bacterial peritonitis • HRS (elevated Cr/BUN with oliguria <400ml/day and urine NA <10meq/l) • Hepatic encephalopathy, refractory to treatment or patient noncompliant • Recurrent variceal bleeding, despite intensive therapy Supportive Factors • Progressive malnutrition • Muscle wasting with reduced strength and endurance • Continued active alcoholism • Hepatocellular carcinoma • HBsAg (Hepatitis B) positive • Hepatitis C refractory treatment
Background: Sepsis Epidemiology 2019 VITAS Healthcare Corporation Adapted from Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1):62-75. • 41% of patients admitted with sepsis die within 90 days • 42% of patients who survive are readmitted within 90 days
Sepsis and Hospice Eligibility: Hospital • Hospice-eligible, not previously identified: – Cancer, solid tumor, and hematologic – Advanced cardiac disease – Advanced lung disease – Dementia Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Network Open, 2(2), e187571-e187571. • Clinical complications of sepsis associated with death: – Vasopressors – Mechanical ventilation – Hyperlactatemia – Acute kidney injury – Hepatic injury – Thrombocytopenia
Factors Associated With Hospital-Related Death Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Network Open, 2(2), e187571-e187571. 0 10 20 30 40 50 60 Thrombocytopenia Hepatic injury Acute kidney injury Hyperlactatemia Mechanical ventilation initiation Vasopressor initiation Organ Dysfunction or Associated Mortality A greater number of organs with dysfunction increases the likelihood of hospital death and the need for a goals-of-care conversation. Organ dysfunction or mortality, % 0 20 40 60 80 100 ≥4 ≥3 ≥2 ≥1 Associated Mortality by Number of Organ Dysfunction Criteria Met Organ dysfunction or mortality, % Number of criteria met Proportion of sepsis cases with organ dysfunction Associated mortality
Sepsis and Hospice Guidelines: Hospitals Discharge • Hospice-eligible, not previously identified – Cancer, solid tumor, and hematologic – Advanced cardiac disease – Advanced lung disease – Dementia • Pre-hospital functional ability – Physical impairment • 1 of 6 ADL or 1 of 5 IADL – Cognitive status • Any degree of dementia
Pre-Sepsis Function and Cognition on Post-Hospital Survival Iwashyna, T., et al. (2010). Long-Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16):1797-1794. • Patients with functional and cognitive impairment prior to sepsis who survive hospitalization have a high 6-month mortality that supports hospice as a relevant and important post-acute care option Pre-Sepsis Disability and Survival Pre-Sepsis Cognition and Survival
ESRD: Age and Survival Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 146(3):177-83.
ESRD: Functional Status and Survival Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 146(3):177-83.
Change in Functional Status After Initiation of Dialysis Tamura, M. (2009). Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 361:1539-1547. 0 20 40 60 80 100 3 6 9 12 Residents (%) Months Since Initiation of Dialysis Died Functional status decreased Functional status maintained
Dialysis Withdrawal O’Connor, N., et al. (2013). Survival after dialysis discontinuation and hospice enrollment for ESRD. Clinical Journal of the American Society of Nephrology, 8(12):2117-2122. Factor Median Survival (days) PPS 10 – 20 3 (1 – 4) PPS > 20 7 (3 – 9) Oxygen Use 6 (3 – 9) No Oxygen Use 7 (4 – 9) Peripheral Edema 4 (2 – 5) No Peripheral Edema 8 (5 – 11) (Mean Survival – 7.4 days)
Dialysis related to dying process Patient wishes to discontinue dialysis Dialysis unrelated to terminal prognosis No change in treatment approach Discontinuation of dialysis Continue dialysis as prior to hospice Once discontinued, average survival 7 to 10 days Dialysis unrelated to dying process so reimbursed separately from hospice Patient Type Dialysis Approach Considerations Not consistent with hospice plan of care Collaboration among hospice and dialysis partner2 YES YES Admit to Hospice? Anticipated stop date or prognosis 2 month or less1 Palliative dialysis Primary goal of symptom management and consistent with hospice plan of care Work to identify discontinuation date and rationale Collaboration among hospice and dialysis partner2 NO 1. Often patients endorse a comfort-focused approach to care and either: • Have a stop date to reach a milestone or to attend an event a month or less away • Maintain a prognosis of 2 months or less 2. Collaboration incorporates GM and medical director with dialysis partner about number of sessions, treatments (reuse, filters,” and solutions), electrolyte management, access, nephrology/professional support, and transportation needs. VITAS® Healthcare ESRD Care Considerations for Patients Receiving Dialysis
Summary • Prognosis is an important determination as part of medical care • Ability improves with clinical experience, but declines with patient- clinician experience • Hospice prognosis threshold is 6 months or less if the illness runs its normal course • Incorporate general domains of decline along with disease-specific factors
Questions?
Scan now to download the VITAS app. Additional Hospice Resources • The VITAS mobile app includes helpful tools and information: • Interactive Palliative Performance Scale (PPS) • Body-Mass Index (BMI) calculator • Opioid converter • Disease-specific hospice eligibility guidelines • Hospice care discussion guides We look forward to having you attend some of our future webinars!
Almagro, P., et al. (2017). Palliative care and prognosis in COPD: a systematic review with a validation cohort. International Journal of COPD, 12:1721-1729. Anderson, F., et al. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1):5-11. Baik, D., et al. (2018). Using the palliative performance scale to estimate survival for patients at the end of life: A systematic review of the literature. Journal of Palliative Medicine, 21(11): 1651-1661. Boyd, C., et al. (2008). Recovery in activities of daily living among older adults following hospitalization for acute medical illness. Journal of the American Geriatric Society, 6(12): 2171-2179. Cabre, M., et al. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 39:39-45. Christakis, N., et al. (2000). Extent and determinants of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320(7233):469-72. Creber, R., et al. (2019). Use of the palliative performance scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378. Downar, J., et al. (2017). The “surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. CMAJ. 189(13):E484-E493. Fox, E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA, 282(17):1638-45. References
References Gill, T., et al. (2019). Taking to bed at the end of life. JAGS, 67(6), 1248–1252. Gramling, et al. (2019). Palliative care clinician overestimate of survival in advanced cancer: Disparities and association with end-of-life care. Journal of Pain and Symptom Management, 57(2):233-240. Jang, R., et al. (2014) Simple prognostic model for patients with advanced cancer based on performance status. American Society of Clinical Oncology. Kheirbek, R. et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740. Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 6;146(3):177-83. Lunney, J., et al. (2003). Patterns of functional decline at the end of life. JAMA, 289:2387-2392. Lunney, J., et al. (2018). Mobility trajectories at the end of life: Comparing clinical conditions and latent class approaches. Journal of the American Geriatric Society, 66:503-508. Lynn, J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health. Mackillop, W., et al. (1997). Measuring the accuracy of prognostic judgments in oncology. Journal of Clinical Epidemiology, 50:21-29. Marton, K., et al. (1981). Involuntary weight loss: Diagnostic and prognostic significance. Annals of Internal Medicine, 95(5):568-74. Medicare Benefit Policy Manual (Rev. 246, 09-14-18).
References Mitchell, S., et al. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361:1529-1538. Morrison, R., et al. (2000). Survival in end-stage dementia following acute illness. JAMA, 284(1):47-52. Palliative Care Network of Wisconsin. (2015, May). Fast Fact Number 13. Retrieved from: https://www.mypcnow.org/ blank- hh45g Ryan, C., et al. (1995). Unintentional weight loss in long-term care: Predictor of mortality in the elderly. Southern Medical Journal, 88(7):721-724. Miyagishima, K., et al. (2009). Long term prognosis of chronic heart failure reduced vs preserved left ventricular ejection fraction. Circulation Journal, 73: 92–99. Neale, R., et al. (2001). Cognition and survival: An exploration of a large multicenter study of a population aged 65 years and older. International Journal of Epidemiology, 30:1383-1388. O'Connor, N., et al. (2013). Survival after dialysis discontinuation and hospice enrollment for ESRD. 8(12):2117-2122. O’Hare, A., etClinical Journal of the American Society of Nephrology, al. (2018). Hospice use and end-of-life spending trajectories in Medicare beneficiaries on hemodialysis. Health Affairs, 37:980–987. Olajide, O., et al. (2007). Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine, 10(1):111-7. Shah, K. et al. (2017). Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology, 70.20: 2476-2486.
Shen, J., et al. (2018). Life-sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014. Journal of Palliative Care, 33(3): 159-166. Soones, T., et al. (2017). Two-year mortality in homebound older adults: An analysis of the National Health and Aging Trends Study. Journal of American Geriatric Society, 65:123–12 Stineman, M., et al. (2012). All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage. Journal of the American Geriatric Society, 60(3):485-92. Tamura, M. (2009). Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 61:1539-1547. Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival? JAGS, 60(10): 1918–1921. Teno, J., et al. (2013). Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA, 310(3). Wild, D. (1981). How dangerous are falls in old people at home? British Medical Journal (Clinical Research Edition), 282(6260): 266–268. Wong, S., et al. (2012). Treatment intensity at the end of life in older adults receiving long-term dialysis. Archives of Internal Medicine, 172(8):661-663. Wright, J., et al. (2011). End-of-life care: A practical guide. New York: McGraw Hill, p. 19. Zippirich, H., et al. (2020). Outcome of older patients with neuropsychological symptoms not fulfilling criteria of delirium. JAGS, 68:1469-1475. References

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Determining Prognosis in Cancer and Non-Cancer Diagnoses

  • 1.
    Determining Prognosis in Cancerand Non-Cancer Diagnoses
  • 2.
    Satisfactory Completion Learners mustcomplete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CME Provider Information
  • 3.
    CE Provider Information VITAS® Healthcareprograms are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling. VITAS® Healthcare programs in California/Connecticut/Delaware/ Illinois/Northern/Virginia/Ohio/Pennsylvania/Washington DC/ Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/2021-06/06/2024). Social Workers participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers completing this course receive 1.0 continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2025. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
  • 4.
    Goal The goal ofthis presentation is to help healthcare professionals identify when patients are entering the end stages of cancer and non-cancer diagnoses that support hospice eligibility.
  • 5.
    Objectives • Appreciate therole of determining a patient’s prognosis • Define the Medicare Hospice Benefit, including eligibility requirements • Understand the theoretical trajectories of dying • Recognize six general domains of decline that support poor prognosis and clinical progression of disease • Describe disease-specific factors that help determine prognosis in patients with cancer and non-cancer diagnoses
  • 6.
    “Medicine is ascience of uncertainty and an art of probability.” —Sir William Osler "Father of Modern Medicine"
  • 7.
    Prognosis and Practiceof Medicine • What to expect from an individual’s disease course • Clinicians’ prognostic estimates are a framework to make informed decisions about care – Health screening – Disability outcomes – Disease management – Advance care planning – End-of-life decisions, including hospice enrollment
  • 8.
    Medicare Hospice Benefit MedicareBenefit Policy Manual (Rev. 246, 09-14-18). Terminal illness: “A medical prognosis (of a) life expectancy of 6 months or less, as determined by 2 physicians, if the illness runs its normal course.”
  • 9.
    Medicare Hospice Benefit(cont.) Benefits Protection and Improvement Act (BIPA) of 2000 Certification of terminal illness of an individual who elects hospice “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”
  • 10.
    Predicting Prognosis Christakis, N.,et al. (2000). Extent and determination of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320:269. • 20% of the doctors’ predictions were accurate, 63% were over-optimistic, and 17% over pessimistic • Greater experience = better prediction accuracy • Longer relationship with a clinician = worse prediction accuracy A recent study found palliative clinicians overestimate survival by 85%, leading to less hospice use and shorter stays.
  • 11.
    Lunney, J., etal. (2003). Patterns of functional decline at the end of life. JAMA, 289:2387-2392. Lunney, J., et al. (2018). Mobility trajectories at the end of life: Comparing clinical conditions and latent class approaches. Journal of the American Geriatric Society, 8;66: 503-508. Theoretical Trajectories of Dying Dependence on ADLs Prior to Death 1 year 1 month Terminal Illness 0.77 4.09 Organ Failure 2.10 3.66 Frailty 2.92 5.84
  • 12.
    General Domains toConsider • Clinical judgment • Nutrition • Physical function • Cognition • Healthcare utilization • Symptoms
  • 13.
    Clinical Judgment • Wouldyou be surprised if this patient were to die in the next year?
  • 14.
    Surprise Question Downar, J.,et al. (2017). The "surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. CMAJ, 189(13):E484-E493. • Would you be surprised if this patient were to die in the next year? • Recent meta-analysis – Sensitivity – Specificity – PPV – NPV – AUC 67.0% (55.7%–76.7%) 80.2% (73.3%–85.6%) 37.1% (30.2%–44.6%) 93.1% (91.0%–94.8%) 0.81 (95% CI 0.78–0.86)
  • 15.
    Nutritional Status • Weightchange – ≥ 10% of normal body weight in 6 months – ≥ 5% of normal body weight in 1 month • BMI change (BMI < 22) • Albumin level • Choking and/or pocketing food • Wounds • Muscle wasting – Sarcopenia – Temporal wasting
  • 16.
    Long-Term Care 153 residents •24 lost 5% weight in 1 month • 5.1 times more likely to die in 1 year Outpatient Prospective evaluation of 91 patients with weight loss • 35% no identifiable cause • 25% died over the ensuing year Weight Loss and Prognosis Ryan, C., et al. (1995). Unintentional weight loss in long term care: Predictor of mortality in the elderly. Southern Medical Journal, 88(7):721-724. Marton, K., et aI. (1981). Involuntary weight loss: Diagnostic and prognostic significance. Annals of Internal Medicine, (5):568-74.
  • 17.
    Cabre, M., etal. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing, 39:39-45. Dysphagia and Survival Mortality with dysphagia: 30-day: 22.9% 1-year: 55.4%
  • 18.
    Malnutrition The criterion inonly one of the columns needs to be achieved in order to qualify for that type of malnutrition. Type of Malnutrition % of Normal Weight BMI Serum Albumin* Normal: No Malnutrition 90-100 19-24 3.5-5.0 Mild 85-89 18-18.9 3.1-3.4 Moderate 75-84 16-17.9 2.4-3.0 Severe < 75 < 16 < 2.4
  • 19.
    Physical Function Palliative PerformanceScale (PPS) • Scale of 0% (dead) to 100% (normal) • Activities of daily living – Bathing – Continence – Dressing – Transferring – Ambulation – Eating • Homebound status • Taking to bed • Falls
  • 20.
    Anderson, F., etal. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1):5-11. Mobility IADLs ADLs % Ambulation Activity and Evidence of Disease Self-Care Intake Level of Consciousness 100 Full Normal Activity Full Normal Full No Evidence of Disease 90 Full Normal Activity Full Normal Full Some Evidence of Disease 80 Full Normal Activity With Effort Full Normal or Reduced Full Some Evidence of Disease 70 Reduced Unable to Do Normal Job/Work Full Normal or Reduced Full Some Evidence of Disease 60 Reduced Unable to Do Hobby/Housework Occasional Assistance Necessary Normal or Reduced Full or Confusion Significant Disease 50 Mainly Sit/Lie Unable to Do Any Work Considerable Assistance Required Normal or Reduced Full or Confusion Extensive Disease 40 Mainly in Bed As Above Mainly Assistance Normal or Reduced Full or Drowsy or Confusion 30 Totally Bed Bound As Above Total Care Reduced Full or Drowsy or Confusion 20 As Above As Above Total Care Minimal Sips Full or Drowsy or Confusion 10 As Above As Above Total Care Mouth Care Only Drowsy or Coma 0 Death -- -- -- -- Based on what the patient can do! Generally Hospice Eligible Palliative Performance Scale
  • 21.
    Survival by PPSat Acute-Care Hospital Olajide, O., et al. (2007). Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine, 10(1):111-7.
  • 22.
    ADL Difficulty Proportion Population Median Survival None 72.1% 10.6yrs Mild 16.1% 6.5 yrs Moderate 7.0% 5.1 yrs Severe 4.3% 3.8 yrs Complete 0.5% 1.6 yrs Activities of Daily Living: Difficulty and Death Stineman, M., et al. (2012). All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage. Journal of the American Geriatric Society, 60(3):485-92.
  • 23.
    Homebound Status and2-Year Mortality Soones, T., et al. (2017). Two-year mortality in homebound older adults: An analysis of the National Health and Aging Trends Study. Journal of American Geriatric Society, 65:123–129. Homebound 12.1% Improved and no longer homebound 26.9% Still homebound 14.9% Semi-homebound 5.8% Nursing home 40.3% Died
  • 24.
    Taking to Bedand Prognosis Gill, T., et al. (2019). Taking to bed at the end of life. JAGS, 67(6), 1248–1252. Bed rest increases as death approaches: • 24 months before death: 12.4% • 5 months before death: 19.0% • 1 month before death: 51.6% The number of days of bed rest increases as death approaches: • 4 months before death: 7 days of bed rest • 1 month before death: 14 days of bed rest Almost 90% take to bed prior to death, and number of days in bed increases.
  • 25.
    25% of thosewho fell died within 1 year. Falls and One-Year Mortality Wild, D. (1981). How dangerous are falls in old people at home? British Medical Journal (Clinical Research Edition), 282(6260): 266–268. Cause Fallers Controls Cerebral vascular accident 7 2 Bronchopneumonia 12 3 Carcinoma 3 1 Congestive cardiac failure 5 1 Myocardial infarction 5 1 Total 32 8 4 0 0 1 2 3 4 5 6 7 8 9 10 11 12 8 24 20 16 12 28 32 Number of Deaths Months After Index Fall Cumulative mortality in 125 fallers and 125 controls in 12 months after index fall. Fallers Controls
  • 26.
    Cognitive Decline • Orientationto person, place, and time • State of consciousness: Awake or asleep in 24 hours • Ability to communicate and follow commands • Ability to recognize environment
  • 27.
    Cognition and Survival Neale,R., et al. (2001). Cognition and survival: An exploration of a large multicenter study of a population aged 65 years and older International. International Journal of Epidemiology, 30:1383-1388.
  • 28.
    Increased Healthcare Utilization •Clinic visits • Subspecialty visits • Emergency department visits • Hospitalizations
  • 29.
    Hospitalization, ADL Change,and Death Boyd, C., et al. (2008). Recovery in activities of daily living among older adults following hospitalization for acute medical illness. Journal of the American Geriatric Society, 56(12): 2171-2179. 83.8% 33.5% 80.0% 37.4% 73.7% 36.5% 67.0% 30.1% 13.5% 53.0% 12.9% 40.2% 14.9% 32.4% 15.2% 28.6% 2.7% 13.5% 7.1% 22.4% 11.4% 31.2% 17.8% 41.3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Discharged at baseline function Discharged with a new or additional disability in ADL Discharged at baseline function Discharged with a new or additional disability in ADL Discharged at baseline function Discharged with a new or additional disability in ADL Discharged at baseline function Discharged with a new or additional disability in ADL Baseline Decline Death 1 month 3 months 6 months 12 months
  • 30.
    Uncontrolled Symptoms • Pain •Shortness of breath • Delirium • Agitation • Nausea and vomiting • Constipation • Exhaustion, fatigue, low activity
  • 31.
    Acute Neuropsychological Symptomsand Mortality Zippirich, H., et al. (2020). Outcome of older patients with acute neuropsychological symptoms not fulfilling criteria of delirium. JAGS, 68:1469-1475. Changes in mental status that may prompt an evaluation of delirium Confusion Assessment Method (CAM) Features of Delirium: 1. Acute onset of changes or fluctuation in mental status 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness • Delirium is diagnosed when features 1 and 2, plus either feature 3 or 4, are present • Exhibiting only 2 of the 4 CAM features indicates symptoms of delirium 37.7 44.3 36.1 41.8
  • 32.
    Indicators of PoorPrognosis in Cancer and Non-Cancer Diagnoses
  • 33.
    Cancer Trajectory Christakis, N.,et al. (2000). Extent and determinants of error in doctors’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320(7233):469-72. Mackillop, W., et al. (1997). Measuring the accuracy of prognostic judgements in oncology. Journal of Clinical Epidemiology, 50:21-29. Function Death is more predictable Low Onset of illness Decline usually 3-6 month Slower trajectory for hormone-sensitive tumors, i.e., breast, prostate High Functional Status: Key Determinant Prognosis ECOG 3: 50% of time in bed or chair; hospice eligible
  • 34.
    ECOG 0: Fully active,able to carry on all pre-disease performance without restriction. 1: Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature. 2: Ambulatory. Able to self-care. Unable to carry out work activities. 3: Limited self-care. Confined to bed/chair > 50%. 4: Disabled. Unable to self-care. Totally confined to bed/chair. 5: Dead. Jang, R., et al. (2014). Simple prognostic model for patients with advanced cancer based on performance status. American Society of Clinical Oncology. Cancer, Function, and Prognosis
  • 35.
    Cancer Prognosis: HelpfulNumbers Palliative Care Network of Wisconsin. (2015, May). Fast Fact Number 13. Retrieved from: https://www.mypcnow.org/blank-hh45g Cancer Syndrome Estimated Survival Malignant hypercalcemia 8 weeks (except newly diagnosed breast or MM) Malignant pericardial effusion 8 weeks Carcinomatous meningitis 8-12 weeks Multiple brain metastases 1-2 months no XRT; 3-6 months with XRT Malignant ascites Less than 6 months Malignant pleural effusion Less than 6 months Malignant bowel obstruction Less than 6 months
  • 36.
    Heart Failure Trajectory Lynn,J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health. Function Low NYHA Class III/IV Hospice Eligible NL and low EF maintain a similar trajectory and prognosis High Death NYHA Symptoms: Shortness of breath • Fatigue Chest pain • Palpitations Multiple Hospitalizations Death After Exacerbation
  • 37.
    Median Survival inHeart Failure (HF) Patients by Age1 1 Shah, K., et al. (2017). Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology, 70.20: 2476-2486. 2Kheirbek, R., et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740. Hospitalization for HF is associated with a poor long-term prognosis and an elevated risk of cardiovascular (CV) and HF admission, irrespective of ejection fraction (EF). • Across all age groups, patients with HF (regardless of EF) had a markedly lower median survival than the life expectancy of individuals in the US • The median survival for patients with HF was similar by EF group but declined with advancing age • Factors associated with an even poorer prognosis include NYHA Class, hospitalization, weight loss, O2 use, renal insufficiency, anemia 18.7 15.1 11.9 9.1 6.8 5 3.6 2.9 2.3 1.7 1.2 0.8 3.3 2.8 2.6 1.8 1.3 1 4 3.4 2.6 2.2 1.5 0.9 0 5 10 15 20 65-69 70-74 75-79 80-84 85-89 ≥90 Median Survival in Years Ages in Years Median Survival Stratified by Age Life Expectancy in US HFrEF Patients HFbEF Patients HFpEF Patients Only 1 in 10 patients with advanced heart failure is referred to hospice2
  • 38.
    HF and Prognosis PrognosisTool Components Comments NYHA Class 1-year mortality listed I N/A II.7% III.13% IV.40-60% Patients can move among classes based upon response treatment Cachexia 7.5% weight loss 29% die 6 months 42% die 18 months Dry weight; independent age, NYHA, and EF Seattle Heart Failure Age, gender, NYHA Class, EF, BP, laboratory data, medications, and presence of devices. Predictors survival: NYHA class, EF, Na, SBP, ischemic etiology Predicts mean, 1-, 2-, and 5-year survival; overestimates at patient level; Based upon reduced EF mostly Surprise Question in HF Would you be surprised if this patient died within next year? Sensitivity 85%, NPV 88% Specificity 59%PPV 52%
  • 39.
    Functional Status PredictsHospice Eligibility in Cardiac Patients Creber, R., et al., (2019). Use of the palliative performance scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378. Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible. PPS Score Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level 60 Reduced Unable to do hobby/housework Occasional assistance Significant disease necessary Full or 50 Mainly sit/lie Unable to do any housework Extensive disease Considerable assistance required Normal or confusion 40 Mainly in bed Unable to do most activities Extensive disease Mainly assistance reduced Full or drowsy 30 Totally bedbound Unable to do any activities Extensive disease Requires total care +/- confusion
  • 40.
    Advance Cardiac HospiceEligibility Guidelines Patient is: • Optimally treated • Not a candidate/pursuing surgical options Symptoms include: • Fatigue • Dyspnea • Angina • Palpitations NYHA Class III: • Symptoms during less-than-ordinary activity • Significant comorbidities NYHA Class IV: • Symptoms at rest • Physical activity causes further discomfort Or Functional status and symptom burden are strongest indicators of hospice eligibility Significant Comorbidities with Poor Prognosis • Uncontrolled hypertension/hypotension • Uncontrolled diabetes with complications • Coronary artery disease • Prior MI or syncope • Renal dysfunction or CKD • Valvular heart disease • Frailty • Cognitive impairment • Malnutrition, cachexia • Ventricular arrhythmias • Older age at diagnosis • Lab/imaging abnormalities: hyponatremia, elevated BNP, or NT-proBNP • Dependence on inotropes
  • 41.
    COPD Trajectory Fox, E.,et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA, 282(17):1638–1645. Function Death Low High Multiple Hospitalizations Death After Exacerbation COPD patients often expire surrounding hospital Ongoing Lung Function Decline Despite Treatment, Accompanied by Hospitalizations and Progressive Dyspnea Hospice Eligible
  • 42.
    COPD and Prognosis Fox,E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. JAMA, 282(17):1638-45. Almagro, P., et al. (2017). Palliative care and prognosis in COPD: A systematic review with a validation cohort. International Journal of COPD, 12:1721-1729. Prognosis of 6 months or less, 2 of 4 criteria • PaCO2 > 45 mmHg • Cor pulmonale • FEV-1 < 0.75 L • Episode of respiratory failure last 12 months
  • 43.
    Lung Disease HospiceEligibility Guidelines Disabling dyspnea as demonstrated by: • Dyspnea at rest or with minimal exertion while on oxygen therapy • Dyspnea unresponsive or poorly responsive to bronchodilators Progressive pulmonary disease manifested by one or more of the following: • Hospitalizations, ER visits, or doctor’s office visits • Frequent episodes of bronchitis or pneumonia • Frequent infections or respiratory failure requiring intubation • Cor pulmonale Supportive Features (ANY) • Unintentional weight loss of > 10% body weight over last 6 months • Resting tachycardia > 100/minute • Progressive inability to independently perform various activities of daily living (ADLs) • Abnormal tests (if available, but not necessary): – pO2 < 55 mmHg – pCO2 > 50 mmHg – O2 saturation < 88% on RA – FEV-1 < 30% predicted, post-bronchodilator And
  • 44.
    CAGR=5.45%, P=.029 CAGR=13.12%, P<.001 CAGR=11.95%, P<.001 CAGR=7.69%, P=.009 CAGR=11.99%, P<.001 COPD and Over-MedicalizedHospital Deaths: 2010 to 2014 Shen, J., et al. (2018). Life sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014. Journal of Palliative Care, 33(3):159-166. The use of ventilation, vasopressors, dialysis, and CPR all increased significantly for COPD patients who died in the hospital from 2010 to 2014. 48.9% of COPD patients who died in the hospital had at least one life-sustaining treatment, with 25% receiving multiple treatments. Compounded Annual Growth Rates by Life-Sustaining Treatment for COPD Patients with Hospital Deaths
  • 45.
    Dementia Trajectory Lynn, J.,et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health. Function Death Low ADL Dependency Slow decline High Functional Dependency and Disease-Related Complication Hospice-Eligible Dependence in 3/6 ADLs (bathing, dressing, feeding, continence, ambulation, transferring) Disease-related complication within last 6 months
  • 46.
    Wright, J., etal. (2011). End-of-life care: A practical guide. New York: McGraw Hill, p. 19. • Pneumonia • Pyelonephritis or upper urinary tract infection • Septicemia • 2 or more pressure ulcers: Stage III or IV • Febrile episodes • Altered nutritional status (weight loss 10% in 6 mo or 5% in 1 mo) • Eating difficulty, including feeding tube decision • Frequent falls or fall with fracture Patient experienced one or more of the following complications in the last 6 months: Dementias and Other End-Stage Neurodegenerative Disorders • Hip fracture, with or without repair • Delirium
  • 47.
    Mitchell, S., etal. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361:1529-1538. • Median survival was 478 days, 24.7% within 6 months • 54.8% died, 93.8% in NH 6-month mortality 38.6% 6-month mortality 44.5% 6-month mortality 46.7% Natural History of Dementia
  • 48.
    Morrison, R., etal. (2000). Survival in end-stage dementia following acute illness. JAMA, 284(1):47-52. Hip Fracture If impaired 55% Survival After Acute Illness: Severe Dementia vs. Cognitively Intact 6-month mortality If intact 12% Pneumonia If impaired 53% 6-month mortality If intact 13%
  • 49.
    1-Year Survival FromBaseline by FT Status Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival? JAGS, 60(10):1918–1921.
  • 50.
    Teno, J., etal. (2013). Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA, 310(3). Two or More Hospitalizations of Nursing Home Residents With Dementia in One Year
  • 51.
    Dementia Hospice EligibilityGuidelines Alzheimer’s Disease Lose ability to speak or communicate meaningfully (FAST 7A) Non-Alzheimer’s Disease or Mixed Dress • Incontinence of bowel and bladder Transferring • Ambulation • Eating • Bathing Plus have either A comorbidity resulting in structural/functional impairment: • Heart Disease (e.g., Heart Failure, Advanced Cardiac Disease, etc.) • Advanced Lung Disease (COPD) Or A clinical complication indicative of disease progression: • Febrile episode • Infection requiring antibiotics (aspiration pneumonia, UTI, sepsis) • Eating difficulty including dysphagia • Delirium • Feeding tube decision • Pressure ulcers • Dehydration requiring hospitalization • Weight loss (10% in 6 mo or 5% in 1 mo) • Frequent falls/fall with fracture
  • 52.
    End-Stage Liver DiseaseTrajectory Natural History of Liver Disease Function Death Low Few Symptoms Many Symptoms High Three Hospitalizations last year of life Decompensated cirrhosis + hospitalization- jaundice, ascites, hepatic encephalopathy, and/or variceal hemorrhage 30% one-month readmit rate; one-month hospital last year life; 70% Die in ICU Etiology liver disease: ETOH (45%), Hep C (41%), NASH (26%) Symptoms of Decompensated Cirrhosis • Muscle cramps, 64% • Poor-quality sleep, 63% • Pruritus, 39% • Sexual dysfunction, 53% • Depression, >50% • Anxiety, >50% • Anorexia, >50% • Fatigue, >50%
  • 53.
    Evidence-Based Disease Management Tapper,et al. (2023). "Diagnosis and Management of Cirrhosis and Its Complications: A Review." JAMA 329.(18):1589-1602. Median survival rates: • Variceal bleed: 17.7% 6-wk death • Ascites: 1.1 y • SBP 11%/y: 11 weeks • HRS 8%/y : < 2 weeks • HE: 0.95 y ≥ 65 and 2.5 y (<65) • HE: 0.95 y ≥ 65 & 2.5 y (<65) • HCC: 1-4% per/yr 5-yr survival 20%
  • 54.
    ESLD and HospiceEligibility 1 and 2 must be met 1. The patient should show both an INR>1.5 and a serum albumin <2.5 gm/dl 2. End-stage liver is present, and patient shows at least one of the following: • Ascites, refractory to treatment or patient non-compliant • Spontaneous bacterial peritonitis • HRS (elevated Cr/BUN with oliguria <400ml/day and urine NA <10meq/l) • Hepatic encephalopathy, refractory to treatment or patient noncompliant • Recurrent variceal bleeding, despite intensive therapy Supportive Factors • Progressive malnutrition • Muscle wasting with reduced strength and endurance • Continued active alcoholism • Hepatocellular carcinoma • HBsAg (Hepatitis B) positive • Hepatitis C refractory treatment
  • 55.
    Background: Sepsis Epidemiology 2019VITAS Healthcare Corporation Adapted from Prescott, H. & Angus, D. (2018). Enhancing Recovery from Sepsis: A Review. JAMA, 319(1):62-75. • 41% of patients admitted with sepsis die within 90 days • 42% of patients who survive are readmitted within 90 days
  • 56.
    Sepsis and HospiceEligibility: Hospital • Hospice-eligible, not previously identified: – Cancer, solid tumor, and hematologic – Advanced cardiac disease – Advanced lung disease – Dementia Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Network Open, 2(2), e187571-e187571. • Clinical complications of sepsis associated with death: – Vasopressors – Mechanical ventilation – Hyperlactatemia – Acute kidney injury – Hepatic injury – Thrombocytopenia
  • 57.
    Factors Associated WithHospital-Related Death Rhee, C., et al. (2019). Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Network Open, 2(2), e187571-e187571. 0 10 20 30 40 50 60 Thrombocytopenia Hepatic injury Acute kidney injury Hyperlactatemia Mechanical ventilation initiation Vasopressor initiation Organ Dysfunction or Associated Mortality A greater number of organs with dysfunction increases the likelihood of hospital death and the need for a goals-of-care conversation. Organ dysfunction or mortality, % 0 20 40 60 80 100 ≥4 ≥3 ≥2 ≥1 Associated Mortality by Number of Organ Dysfunction Criteria Met Organ dysfunction or mortality, % Number of criteria met Proportion of sepsis cases with organ dysfunction Associated mortality
  • 58.
    Sepsis and HospiceGuidelines: Hospitals Discharge • Hospice-eligible, not previously identified – Cancer, solid tumor, and hematologic – Advanced cardiac disease – Advanced lung disease – Dementia • Pre-hospital functional ability – Physical impairment • 1 of 6 ADL or 1 of 5 IADL – Cognitive status • Any degree of dementia
  • 59.
    Pre-Sepsis Function andCognition on Post-Hospital Survival Iwashyna, T., et al. (2010). Long-Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA, 304(16):1797-1794. • Patients with functional and cognitive impairment prior to sepsis who survive hospitalization have a high 6-month mortality that supports hospice as a relevant and important post-acute care option Pre-Sepsis Disability and Survival Pre-Sepsis Cognition and Survival
  • 60.
    ESRD: Age andSurvival Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 146(3):177-83.
  • 61.
    ESRD: Functional Statusand Survival Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 146(3):177-83.
  • 62.
    Change in FunctionalStatus After Initiation of Dialysis Tamura, M. (2009). Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 361:1539-1547. 0 20 40 60 80 100 3 6 9 12 Residents (%) Months Since Initiation of Dialysis Died Functional status decreased Functional status maintained
  • 63.
    Dialysis Withdrawal O’Connor, N.,et al. (2013). Survival after dialysis discontinuation and hospice enrollment for ESRD. Clinical Journal of the American Society of Nephrology, 8(12):2117-2122. Factor Median Survival (days) PPS 10 – 20 3 (1 – 4) PPS > 20 7 (3 – 9) Oxygen Use 6 (3 – 9) No Oxygen Use 7 (4 – 9) Peripheral Edema 4 (2 – 5) No Peripheral Edema 8 (5 – 11) (Mean Survival – 7.4 days)
  • 64.
    Dialysis related to dying process Patient wishes todiscontinue dialysis Dialysis unrelated to terminal prognosis No change in treatment approach Discontinuation of dialysis Continue dialysis as prior to hospice Once discontinued, average survival 7 to 10 days Dialysis unrelated to dying process so reimbursed separately from hospice Patient Type Dialysis Approach Considerations Not consistent with hospice plan of care Collaboration among hospice and dialysis partner2 YES YES Admit to Hospice? Anticipated stop date or prognosis 2 month or less1 Palliative dialysis Primary goal of symptom management and consistent with hospice plan of care Work to identify discontinuation date and rationale Collaboration among hospice and dialysis partner2 NO 1. Often patients endorse a comfort-focused approach to care and either: • Have a stop date to reach a milestone or to attend an event a month or less away • Maintain a prognosis of 2 months or less 2. Collaboration incorporates GM and medical director with dialysis partner about number of sessions, treatments (reuse, filters,” and solutions), electrolyte management, access, nephrology/professional support, and transportation needs. VITAS® Healthcare ESRD Care Considerations for Patients Receiving Dialysis
  • 65.
    Summary • Prognosis isan important determination as part of medical care • Ability improves with clinical experience, but declines with patient- clinician experience • Hospice prognosis threshold is 6 months or less if the illness runs its normal course • Incorporate general domains of decline along with disease-specific factors
  • 66.
  • 67.
    Scan now to downloadthe VITAS app. Additional Hospice Resources • The VITAS mobile app includes helpful tools and information: • Interactive Palliative Performance Scale (PPS) • Body-Mass Index (BMI) calculator • Opioid converter • Disease-specific hospice eligibility guidelines • Hospice care discussion guides We look forward to having you attend some of our future webinars!
  • 68.
    Almagro, P., etal. (2017). Palliative care and prognosis in COPD: a systematic review with a validation cohort. International Journal of COPD, 12:1721-1729. Anderson, F., et al. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1):5-11. Baik, D., et al. (2018). Using the palliative performance scale to estimate survival for patients at the end of life: A systematic review of the literature. Journal of Palliative Medicine, 21(11): 1651-1661. Boyd, C., et al. (2008). Recovery in activities of daily living among older adults following hospitalization for acute medical illness. Journal of the American Geriatric Society, 6(12): 2171-2179. Cabre, M., et al. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 39:39-45. Christakis, N., et al. (2000). Extent and determinants of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 320(7233):469-72. Creber, R., et al. (2019). Use of the palliative performance scale to estimate survival among home hospice patients with heart failure. ESC Heart Failure, 6(2), 371-378. Downar, J., et al. (2017). The “surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. CMAJ. 189(13):E484-E493. Fox, E., et al. (1999). Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA, 282(17):1638-45. References
  • 69.
    References Gill, T., etal. (2019). Taking to bed at the end of life. JAGS, 67(6), 1248–1252. Gramling, et al. (2019). Palliative care clinician overestimate of survival in advanced cancer: Disparities and association with end-of-life care. Journal of Pain and Symptom Management, 57(2):233-240. Jang, R., et al. (2014) Simple prognostic model for patients with advanced cancer based on performance status. American Society of Clinical Oncology. Kheirbek, R. et al. (2015). Discharge hospice referral and lower 30-day all-cause readmission in Medicare beneficiaries hospitalized for heart failure. Circulation: Heart Failure, 8(4), 733-740. Kurella, M., et al. (2007). Octogenarians and nonagenarians starting dialysis in the United States. Annals of Internal Medicine, 6;146(3):177-83. Lunney, J., et al. (2003). Patterns of functional decline at the end of life. JAMA, 289:2387-2392. Lunney, J., et al. (2018). Mobility trajectories at the end of life: Comparing clinical conditions and latent class approaches. Journal of the American Geriatric Society, 66:503-508. Lynn, J., et al. (2003) Living well at the end of life. Adapting health care to serious chronic illness in old age. Washington: Rand Health. Mackillop, W., et al. (1997). Measuring the accuracy of prognostic judgments in oncology. Journal of Clinical Epidemiology, 50:21-29. Marton, K., et al. (1981). Involuntary weight loss: Diagnostic and prognostic significance. Annals of Internal Medicine, 95(5):568-74. Medicare Benefit Policy Manual (Rev. 246, 09-14-18).
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    References Mitchell, S., etal. (2009). The clinical course of advanced dementia. New England Journal of Medicine, 361:1529-1538. Morrison, R., et al. (2000). Survival in end-stage dementia following acute illness. JAMA, 284(1):47-52. Palliative Care Network of Wisconsin. (2015, May). Fast Fact Number 13. Retrieved from: https://www.mypcnow.org/ blank- hh45g Ryan, C., et al. (1995). Unintentional weight loss in long-term care: Predictor of mortality in the elderly. Southern Medical Journal, 88(7):721-724. Miyagishima, K., et al. (2009). Long term prognosis of chronic heart failure reduced vs preserved left ventricular ejection fraction. Circulation Journal, 73: 92–99. Neale, R., et al. (2001). Cognition and survival: An exploration of a large multicenter study of a population aged 65 years and older. International Journal of Epidemiology, 30:1383-1388. O'Connor, N., et al. (2013). Survival after dialysis discontinuation and hospice enrollment for ESRD. 8(12):2117-2122. O’Hare, A., etClinical Journal of the American Society of Nephrology, al. (2018). Hospice use and end-of-life spending trajectories in Medicare beneficiaries on hemodialysis. Health Affairs, 37:980–987. Olajide, O., et al. (2007). Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine, 10(1):111-7. Shah, K. et al. (2017). Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology, 70.20: 2476-2486.
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    Shen, J., etal. (2018). Life-sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals: 2010-2014. Journal of Palliative Care, 33(3): 159-166. Soones, T., et al. (2017). Two-year mortality in homebound older adults: An analysis of the National Health and Aging Trends Study. Journal of American Geriatric Society, 65:123–12 Stineman, M., et al. (2012). All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage. Journal of the American Geriatric Society, 60(3):485-92. Tamura, M. (2009). Functional status of elderly adults before and after initiation of dialysis. New England Journal of Medicine, 61:1539-1547. Teno, J., et al. (2012). Does feeding tube insertion and its timing improve survival? JAGS, 60(10): 1918–1921. Teno, J., et al. (2013). Survival after multiple hospitalizations for infections and dehydration in nursing home residents with advanced cognitive impairment. JAMA, 310(3). Wild, D. (1981). How dangerous are falls in old people at home? British Medical Journal (Clinical Research Edition), 282(6260): 266–268. Wong, S., et al. (2012). Treatment intensity at the end of life in older adults receiving long-term dialysis. Archives of Internal Medicine, 172(8):661-663. Wright, J., et al. (2011). End-of-life care: A practical guide. New York: McGraw Hill, p. 19. Zippirich, H., et al. (2020). Outcome of older patients with neuropsychological symptoms not fulfilling criteria of delirium. JAGS, 68:1469-1475. References