18.1 (2.3) Predicting survival in patients with advanced disease

Question 1

List three components of the clinical act of prognostication

Answer 1

formulating a prognosis

communication prognosis

using prognosis when making clinical decisions

Question 2

List 3 ways to formulate a prognosis

Answer 2

1. Clinician-based - involves the use of subjective judgement, clinical experience, guidelines and research knowledge of clinician
2. Model-based - depends on statistical data and models (e.g. nomograms, prognosis scores, algorithms)
3. Mixed clinician- and model-based approach - uses both (e.g. clinician use BODE for COPD + clinical factors)

Question 3

List 3 characteristics of a well designed study to evaluate the association between prognosis and survival

Answer 3

◆ A well-defined study population*
◆ Sample size is adequate for statistical power*
◆ Complete follow-up of all patients*

◆ Inception cohort design

◆ Prognostic factors selected are appropriate and clearly defined
◆ Clearly defined end point

◆ Data analysis is appropriate to test associations between the study factors and survival
◆ A measure of agreement between the predicted and actual survival
◆ The definition of accuracy is explicit and appropriate
◆ The prediction tested mirrors clinical language or practice
(i.e. not hazard ratios).

Question 4

List two ways of stating a prognosis.

Answer 4

temporal prediction - time to event expressed as a continuous variable (e.g. 2-3 weeks)

probabilistic prediction - the % chance of an event happening in particular time (e.g. mortality in 6 months is 70%)

Question 5

How effective is the “surprise question”?

Which population is it worse in?

Answer 5

Poor to moderately accurate tool for mortality prediction (performing worse in non-cancer patients)

Question 6

List 5 factors that are considered in prognostication tools

Answer 6

*Performance status - PPS, KPS, ECOG

*Presence of certain key symptoms - SOB, anorexia, delirium

*Mood - depression is correlated to higher mortality

QOL and self rated health

*Comorbidities - eg presence of cancer

*Biomarkers - e.g. BNP in CHF, Na/K/GFR in kidney failure, bili in MELD, CRP and albumin

Genetics

Question 7

What 3 key symptoms are prognostically significant?

Answer 7

dyspnea

anorexia/cachexia

Delirium

Question 8

Identify two prognosis models that can be used in patients with advanced cancer

Answer 8

Palliative prognostic index (PPI) - use PPS, oral intake, SOB, delirium, edena

Palliative prognostic score (PaP) - use KPS, anorexia, dyspnea, WBC, lymphocyte, clinician proediction of survival

Prognosis in Palliative Care Study (PiPS) - use HR, health status, mental test score, PPS, anorexia, site of mets, liver mets, BWK

Modified Glasgow Prognostic Score (m-GPS) - use CPR and albumin

Question 9

List 5 categories on the palliative performance scale

Answer 9

ambulation
activity level/evidence of disease (IADL)
self care (ADL)
intake
LOC

Question 10

Name 2 prognostication tools for CHF

Answer 10

NYHA classification category (NYHA class IV has 1 year mortality of 30-40%)

Seattle Heart Failure Model

Question 11

Name 2 prognostication tools for COPD - what factors do they look at?

Answer 11

BODE = BMI, obstruction (FEV1), dyspnea (MRC dyspnea scale), exercise capacity (6 min walk distance)

HADO = health (self assessment), activity (self assessment), dyspnea, obstuction (FEV1)

Question 12

Name 2 prognostication tools for ESLD - what outcomes are they looking at?

Answer 12

Child Pugh - lab (alb, bili, PTT) + symptom (ascites, encephalopahty) = 1 and 2 year outcomes

MELD (model of end stage liver disease) - lab (bili, creatinine, INR) = 3 months outcome

Question 13

Name 2 prognostication tools for dementia - which is more accurate?

Answer 13

Function assessment staging tool (FAST) - describes stages of dementia based on function

Advanced dementia prognostic tool (ADEPT) - age, sex, weight loss, function, symptoms and continence (more accurate than FAST)

Question 14

What are four techniques for maintaining hope when providing poor prognosis

Answer 14

Retaining professional honesty

Avoiding being blunt or giving more detailed information than desired by the patient

Pacing of information

Exploring and facilitating realistic goals

Respecting patients’ need to follow alternative paths/ treatments

Question 15

List 4 important methods for communicating a prognosis

Answer 15

first clarify the person’s understanding of their medical situation and the information they desire. (K of SPIKE)

tailor information to the individual needs of patients and their families. (I of SPIKE)

communication occurs within the context of a caring, trusting relationship

consistency of information within the multiprofessional team

Question 16

Outline three steps in using best case/worst case approach

Answer 16

1. Clinician outlines treatment options
2. Clinician outlines best, worst and most likely outcomes (can be aided with diagram)
3. After providing patients with information about life expectancy -> explore and acknowledge the patient’s and family’s understanding + emotional reaction