Prognostic uncertainty in terminal care: can the Karnofsky index help?

A predictive model to identify hospitalized cancer patients at risk for 30-day mortality based on admission criteria via the electronic medical record

BACKGROUND

This study sought to develop a predictive model for 30-day mortality in hospitalized cancer patients, by using admission information available through the electronic medical record.

METHODS

Observational cohort study of 3062 patients admitted to the oncology service from August 1, 2008, to July 31, 2009. Matched numbers of patients were in the derivation and validation cohorts (1531 patients). Data were obtained on day 1 of admission and included demographic information, vital signs, and laboratory data. Survival data were obtained from the Social Security Death Index.

RESULTS

The 30-day mortality rate of the derivation and validation samples were 9.5% and 9.7% respectively. Significant predictive variables in the multivariate analysis included age (P < .0001), assistance with activities of daily living (ADLs; P = .022), admission type (elective/emergency) (P = .059), oxygen use (P < .0001), and vital signs abnormalities including pulse oximetry (P = .0004), temperature (P = .017), and heart rate (P = .0002). A logistic regression model was developed to predict death within 30 days: Score = 18.2897 + 0.6013*(admit type) + 0.4518*(ADL) + 0.0325*(admit age) - 0.1458*(temperature) + 0.019*(heart rate) - 0.0983*(pulse oximetry) - 0.0123 (systolic blood pressure) + 0.8615*(O2 use). The largest sum of sensitivity (63%) and specificity (78%) was at -2.09 (area under the curve = -0.789). A total of 25.32% (100 of 395) of patients with a score above -2.09 died, whereas 4.31% (49 of 1136) of patients below -2.09 died. Sensitivity and positive predictive value in the derivation and validation samples compared favorably.

CONCLUSIONS

Clinical factors available via the electronic medical record within 24 hours of hospital admission can be used to identify cancer patients at risk for 30-day mortality. These patients would benefit from discussion of preferences for care at the end of life.

Prognosticating in patients with advanced cancer--observational study comparing the accuracy of clinicians' and patients' estimates of survival

BACKGROUND

Clinicians' prognoses in patients with advanced cancer are imprecise. The aim of this study was to compare doctors', nurses' and patients' survival predictions and to identify factors which influence accuracy.

PATIENTS AND METHODS

Some 1018 patients with advanced cancer were recruited. Survival estimates were obtained from the attending doctor, nurse, multidisciplinary team (MDT) and patient (n = 829, 954, 987 and 290 estimates, respectively) and were compared with actual survival. Clinician and patient characteristics were recorded.

RESULTS

MDTs', doctors' and nurses' predictions were accurate 57.5%, 56.3% and 55.5% of occasions, respectively. Nurses were less accurate than the MDT (P = 0.007) but were no worse than doctors (P = 0.284). Estimates of clinicians and patients were more optimistic (doctors: 31%; nurses: 34%; MDT: 31.1%; patients: 45.1%) than pessimistic (12.7%, 11%, 11.4% and 2.7%). Nurses' accuracy increased if they had reviewed the patient within 24 h. Most patients (61.4%) wanted to know their prognosis. Only 37.1% were willing to offer an estimate regarding their own survival. Patients' prognostic estimates were less accurate than health care professionals' (P < 0.001).

CONCLUSIONS

MDTs were better at predicting survival than doctors' or nurses' alone. Patients were substantially worse. Among nurses, recency of review was related to improved prognostic accuracy.

Assessment of functional status in patients with invasive carcinoma of the urothelial tract

Performance status score is an important prognostic factor for response and survival for patients entering clinical trials. Evaluation of the functional status of the patients should be considered when retrospective studies on prognostic factors are performed. However, the methodologic problems of evaluating performance status retrospectively are unknown. The aim of this study was to evaluate the reliability and validity of retrospective assessment of performance status based on information from patient records. The level of performance status was analyzed in relation to duration of survival after primary or recurrent carcinoma of the urinary tract. The records of 149 patients with primary urothelial carcinoma and 53 patients with recurrent disease were blindly scored twice by two investigators according to the World Health Organization (WHO) performance status scale. The median time of observation was 109 months (range 3-219); 13 patients were alive at the time of follow-up. When scores of the performance were compared for patients separated in two groups, good performance (WHO scores 0 and 1) versus poor performance status (score >1), the intraobserver overall agreement for the assessments varied from 82% to 89%, whereas the interobserver agreement varied from 76% to 86%. The range of the intra- and interobserver kappa coefficients (95% CI) were 63% to 72% (52% to 83%) and 49% to 68% (40% to 79%), respectively. All four assessments were significantly related to survival (p < 10(-4)). Multivariable proportional hazard regression analysis showed that gender, platelet count, level of liver enzymes, and each of the four assessments of performance status (analyzed in four separate statistical models) were significant prognostic factors. Retrospective scoring of performance status is a reproducible and reliable tool that provides additional prognostic information. Optimal retrospective evaluation of the simultaneous effect of multiple prognostic factors should therefore include an assessment of the functional status of the patient.

Prediction of mortality 1 year after hospital admission

OBJECTIVE

Hospital admission, especially for the elderly, can be a seminal event as many patients die within a year. This study reports the prediction of death within a year of admission to hospital of the Simple Clinical Score (SCS) and ECG dispersion mapping (ECG-DM). ECG-DM is a novel technique that analyzes low-amplitude ECG oscillations and reports them as the myocardial micro-alternation index (MMI).

METHODS

a convenient sample of 430 acutely ill medical patients (mean age 67.9 ± 16.6 years) was followed up for 1 year after their last admission to hospital.

RESULTS

Seventy-four (16.3%) patients died within a year-all but seven had a SCS ≥5 and 40% of those with an MMI ≥50% died. Only six of variables were found by logistic regression to be independent predictors of mortality (i.e. age, MMI, SCS, a discharge diagnosis of cancer, hemoglobin <11 gm% and prior illness that required the patient to spend >50% of daytime in bed). The SCS and MMI plus age were comparable predictors of 1-year mortality: SCS ≥12 predicted 1-year mortality with the highest odds (16.1, chi square 79.09, p < 0.0001) and a score of age plus MMI >104 had an odds ratio of 9.4 (chi square 73.50, p < 0.0001), identified 69% of deaths, and 43% of the 119 patients who exceeded this score were dead within a year.

CONCLUSION

SCS and ECG-DM plus age are clinically useful for long-term prognostication. ECG-DM is inexpensive, only takes a few seconds to perform and requires no skill to interpret.

Clinician accuracy when estimating survival duration: the role of the patient's performance status and time-based prognostic categories

CONTEXT

Although shown to be an independent predictor of actual survival (AS) duration, previous reports have identified significant inaccuracy in clinician estimates of survival (CES).

OBJECTIVES

This study aimed to both examine demographic and clinical factors potentially impacting CES accuracy and explore possible strategies for improvement in a patient population with advanced incurable disease.

METHODS

At the time of initial assessment by a specialist palliative care team, CES for each patient was chosen from one of the following time-based categories: <24 hours, one to seven days, one to four weeks, one to three months, three to six months, three to 12 months, or >12 months. Survival estimates were then classified as an accurate (AS=CES), overestimate (AS<CES), or underestimate (AS>CES). Demographic data were analyzed using descriptive statistics, and both univariate and stepwise multivariate logistic regression analyses were used to identify any associated demographic and/or clinical factors significantly impacting accuracy.

RESULTS

Within the total study population of 1835, both CES and AS data were available for 1622 patients among whom mean and median survival was 26.5 and 88 days, respectively. The remaining 213 patients (12% of the total population) remained alive at the time of analysis. Of the total study population, CES was accurate for 34% of patients and an overestimate for 51% of patients. CES of <24 hours and one to seven days were significantly more likely to be accurate than any other prognostic category (P<0.0001). Additionally, a CES of either one to four weeks or >12 months was significantly more likely to be accurate than CES of one to three months, three to six months, and six to 12 months (P<0.0001). Finally, multivariate analyses indicated CES to be significantly more likely to be accurate for males (P=0.0407) and for patients with baseline Palliative Performance Scale (PPS) ratings of either "30 and less" (P<0.0001) or "70 and greater" (P<0.0001).

CONCLUSION

In a patient population referred for specialist palliative care consultation with diverse diagnoses and a wide range of CES, time-based categorization of survival estimates along with PPS and possibly gender could be used to inform the CES process for individual patients. Intentionally incorporating these objective elements into what has historically been the subjective process of CES may lead to improvements in accuracy.

Performance status is the most powerful risk factor for early death among patients with advanced soft tissue sarcoma: the European Organisation for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (STBSG) and French Sarcoma Group (FSG) study

BACKGROUND

We investigated prognostic factors (PFs) for 90-day mortality in a large cohort of advanced/metastatic soft tissue sarcoma (STS) patients treated with first-line chemotherapy.

METHODS

The PFs were identified by both logistic regression analysis and probability tree analysis in patients captured in the Soft Tissue and Bone Sarcoma Group (STBSG) database (3002 patients). Scores derived from the logistic regression analysis and algorithms derived from probability tree analysis were subsequently validated in an independent study cohort from the French Sarcoma Group (FSG) database (404 patients).

RESULTS

The 90-day mortality rate was 8.6 and 4.5% in both cohorts. The logistic regression analysis retained performance status (PS; odds ratio (OR)=3.83 if PS=1, OR=12.00 if PS ≥2), presence of liver metastasis (OR=2.37) and rare site metastasis (OR=2.00) as PFs for early death. The CHAID analysis retained PS as a major discriminator followed by histological grade (only for patients with PS ≥2). In both models, PS was the most powerful PF for 90-day mortality.

CONCLUSION

Performance status has to be taken into account in the design of further clinical trials and is one of the most important parameters to guide patient management. For those patients with poor PS, expected benefits from therapy should be weighed up carefully against the anticipated toxicities.

Randomized trial of the effect of the low molecular weight heparin nadroparin on survival in patients with cancer

PURPOSE

Earlier studies showed that low molecular weight heparin significantly prolongs the survival of a wide variety of patients with cancer without venous thromboembolism. This study was designed to confirm these findings in a more homogeneous group of patients with cancer.

PATIENTS AND METHODS

In this multicenter, randomized, open-label study, patients with non-small-cell lung cancer (stage IIIB), hormone-refractory prostate cancer, or locally advanced pancreatic cancer were randomly assigned to nadroparin or to no nadroparin in addition to their standard anticancer treatment. In the nadroparin arm, subcutaneous nadroparin was administered for 6 weeks (2 weeks at therapeutic dose, and 4 weeks at half therapeutic dose). The patients were eligible to receive additional cycles of nadroparin (2 weeks at therapeutic dose, and 4 weeks of washout period). Outcomes were overall survival, time to progression, and major bleeding. All study outcomes were adjudicated by an independent, blinded committee.

RESULTS

A total of 244 patients were allocated to nadroparin, and 259 were allocated to the control group. A median survival of 13.1 months was observed in the nadroparin recipients compared with 11.9 months in the no-treatment arm (hazard ratio, 0.94; 95% CI, 0.75 to 1.18, adjusted for cancer type). No difference in time to progression was observed. The number of major bleedings was comparable at 4.1% in the nadroparin set and 3.5% in the control set.

CONCLUSION

This study did not show a survival benefit of nadroparin in patients with advanced prostate, lung, or pancreatic cancer. Given the ongoing studies in this area and the previous data, the role of low molecular weight heparins in cancer survival remains undefined.

Association of gender with clinical expression, quality of life, disability, and depression and anxiety in patients with systemic sclerosis

OBJECTIVES

To assess the association of gender with clinical expression, health-related quality of life (HRQoL), disability, and self-reported symptoms of depression and anxiety in patients with systemic sclerosis (SSc).

METHODS

SSc patients fulfilling the American College of Rheumatology and/or the Leroy and Medsger criteria were assessed for clinical symptoms, disability, HRQoL, self-reported symptoms of depression and anxiety by specific measurement scales.

RESULTS

Overall, 381 SSc patients (62 males) were included. Mean age and disease duration at the time of evaluation were 55.9 (13.3) and 9.5 (7.8) years, respectively. One-hundred-and-forty-nine (40.4%) patients had diffuse cutaneous SSc (dcSSc). On bivariate analysis, differences were observed between males and females for clinical symptoms and self-reported symptoms of depression and anxiety, however without reaching statistical significance. Indeed, a trend was found for higher body mass index (BMI) (25.0 [4.1] vs 23.0 [4.5], p = 0.013), more frequent dcSSc, echocardiography systolic pulmonary artery pressure >35 mmHg and interstitial lung disease in males than females (54.8% vs 37.2%, p = 0.010; 24.2% vs 10.5%, p = 0.003; and 54.8% vs 41.2%, p = 0.048, respectively), whereas calcinosis and self-reported anxiety symptoms tended to be more frequent in females than males (36.0% vs 21.4%, p = 0.036, and 62.3% vs 43.5%, p = 0.006, respectively). On multivariate analysis, BMI, echocardiography PAP>35 mmHg, and anxiety were the variables most closely associated with gender.

CONCLUSIONS

In SSc patients, male gender tends to be associated with diffuse disease and female gender with calcinosis and self-reported symptoms of anxiety. Disease-associated disability and HRQoL were similar in both groups.

Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: reality or myth?

BACKGROUND

The purpose of the study was to investigate the adequacy of palliative radiation treatment in end-stage cancer patients.

METHODS

Of 216 patients referred for palliative radiotherapy, 33 died within 30 days and constitute the population of the study. Symptoms, Karnofsky Performance Status (KPS), laboratory tests, and survival estimates were obtained. Treatment course was evaluated by medical records. Univariate analyses were performed by using the 2-sided chi-square test. With significant variables, multiple regression analysis was performed.

RESULTS

Median age was 65 years, and median survival was 15 days. Prevailing primary cancer types were lung (39%) and breast (18%). Metastases were present in 94% of patients, brain (36%), bone (24%) and lung (18%). In 91%, KPS was < 0%. KPS, lactate dehydrogenase, dyspnea, leucocytosis, and brain metastases conveyed a poor prognosis. From 85 survival estimates, only 16% were correct, but 21% expected more than 6 months. Radiotherapy was delivered to 91% of patients. In 90% of radiation treatments, regimens of at least 30 Gy with fractions of 2-3 Gy were applied. Half of the patients spent greater than 60% of their remaining lifespan on therapy. In only 58% of patients was radiotherapy completed. Progressive complaints were noted in 52% and palliation in 26%.

CONCLUSIONS

Radiotherapy was not appropriately customized to these patients considering the median treatment time, which resembles the median survival time. About half of the patients did not benefit despite spending most of their remaining lives on therapy. Prolonged irradiation schedules probably reflect overly optimistic prognoses and unrealistic concerns about late radiation damage. Single-fraction radiotherapy was too seldom used.

Extent and determinants of error in physicians' prognoses in terminally ill patients: prospective cohort study

Objectives To describe physicians' prognostic accuracy in terminally ill patients and to evaluate the determinants of that accuracy. Design Prospective cohort study. Setting Five outpatient hospice programs in Chicago. Participants A total of 343 physicians provided survival estimates for 468 terminally ill patients at the time of hospice referral. Main outcome measures Patients' estimated and actual survival. Results Median survival was 24 days. Of 468 predictions, only 92 (20%) were accurate (within 33% of actual survival); 295 (63%) were overoptimistic, and 81 (17%) were overpessimistic. Overall, physicians overestimated survival by a factor of 5.3. Few patient or physician characteristics were associated with prognostic accuracy. Male patients were 58% less likely to have overpessimistic predictions. Medical specialists excluding oncologists were 326% more likely than general internists to make overpessimistic predictions. Physicians in the upper quartile of practice experience were the most accurate. As the duration of the doctor-patient relationship increased and time since last contact decreased, prognostic accuracy decreased. Conclusions Physicians are inaccurate in their prognoses for terminally ill patients, and the error is systematically optimistic. The inaccuracy is, in general, not restricted to certain kinds of physicians or patients. These phenomena may be adversely affecting the quality of care given to patients near the end of life.

Factor structure of the Beck Hopelessness Scale in individuals with advanced cancer

OBJECTIVE

Although the Beck Hopelessness Scale is often used with the seriously ill, its factor structure has been given relatively little consideration in this context.

METHODS

The factor structure of this scale was examined in a sample of 406 ambulatory patients with advanced lung or gastrointestinal cancer, using a sequential exploratory-confirmatory factor analysis procedure.

RESULTS

A two-factor model was consistent with the data: The first factor reflected a negative outlook and was labeled 'negative expectations'; the second factor identified a sense of resignation and was labeled 'loss of motivation.'

CONCLUSIONS

Implications regarding scoring of the scale in this population are discussed, as are implications of the two-factor structure for our understanding of hopelessness in individuals with advanced cancer.

Relationship between pregnancy-associated plasma protein-A and lung cancer

BACKGROUND

: Pregnancy-associated plasma protein-A (PAPP-A) has insulin-like growth factor (IGF)-dependent IGFBP-4 protease activity and plays an important role in amplifying local IGF-1 activity in wound healing, vascular repair, and bone remodeling. We postulated that PAPP-A may contribute to the availability and activity of IGFs, which affect lung cancer. Therefore, we determined the levels of PAPP-A in patients with lung cancer and their possible clinical significance.

METHODS

: The study population consisted of 83 patients with lung cancer and 33 healthy subjects as a control group. Serum PAPP-A levels were determined using an ultrasensitive enzyme-linked immunosorbent assay.

RESULTS

: The serum PAPP-A levels were higher in patients with lung cancer [median (interquartile range) 10.7 (7.6-14.2) ng/mL] than in the control group [6.2 (5.2-9.8) ng/mL, P < 0.001]. There was a significant negative correlation between the serum PAPP-A levels and Karnofsky performance status (r = -0.330; P < 0.001) and a positive correlation with patient age (r = 0.358; P < 0.001).

CONCLUSION

: PAPP-A is a proatherosclerotic metalloproteinase that is also thought to be an inflammatory marker. We found that the serum PAPP-A levels increased in patients with lung cancer and postulated that PAPP-A levels may be a prognostic factor in such cases.

Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial

BACKGROUND

Small studies of variable quality suggest that massage therapy may relieve pain and other symptoms.

OBJECTIVE

To evaluate the efficacy of massage for decreasing pain and symptom distress and improving quality of life among persons with advanced cancer.

DESIGN

Multisite, randomized clinical trial.

SETTING

Population-based Palliative Care Research Network.

PATIENTS

380 adults with advanced cancer who were experiencing moderate-to-severe pain; 90% were enrolled in hospice.

INTERVENTION

Six 30-minute massage or simple-touch sessions over 2 weeks.

MEASUREMENTS

Primary outcomes were immediate (Memorial Pain Assessment Card, 0- to 10-point scale) and sustained (Brief Pain Inventory [BPI], 0- to 10-point scale) change in pain. Secondary outcomes were immediate change in mood (Memorial Pain Assessment Card) and 60-second heart and respiratory rates and sustained change in quality of life (McGill Quality of Life Questionnaire, 0- to 10-point scale), symptom distress (Memorial Symptom Assessment Scale, 0- to 4-point scale), and analgesic medication use (parenteral morphine equivalents [mg/d]). Immediate outcomes were obtained just before and after each treatment session. Sustained outcomes were obtained at baseline and weekly for 3 weeks.

RESULTS

298 persons were included in the immediate outcome analysis and 348 in the sustained outcome analysis. A total of 82 persons did not receive any allocated study treatments (37 massage patients, 45 control participants). Both groups demonstrated immediate improvement in pain (massage, -1.87 points [95% CI, -2.07 to -1.67 points]; control, -0.97 point [CI, -1.18 to -0.76 points]) and mood (massage, 1.58 points [CI, 1.40 to 1.76 points]; control, 0.97 point [CI, 0.78 to 1.16 points]). Massage was superior for both immediate pain and mood (mean difference, 0.90 and 0.61 points, respectively; P < 0.001). No between-group mean differences occurred over time in sustained pain (BPI mean pain, 0.07 point [CI, -0.23 to 0.37 points]; BPI worst pain, -0.14 point [CI, -0.59 to 0.31 points]), quality of life (McGill Quality of Life Questionnaire overall, 0.08 point [CI, -0.37 to 0.53 points]), symptom distress (Memorial Symptom Assessment Scale global distress index, -0.002 point [CI, -0.12 to 0.12 points]), or analgesic medication use (parenteral morphine equivalents, -0.10 mg/d [CI, -0.25 to 0.05 mg/d]).

LIMITATIONS

The immediate outcome measures were obtained by unblinded study therapists, possibly leading to reporting bias and the overestimation of a beneficial effect. The generalizability to all patients with advanced cancer is uncertain. The differential beneficial effect of massage therapy over simple touch is not conclusive without a usual care control group.

CONCLUSION

Massage may have immediately beneficial effects on pain and mood among patients with advanced cancer. Given the lack of sustained effects and the observed improvements in both study groups, the potential benefits of attention and simple touch should also be considered in this patient population.

Patient preference disability questionnaire in systemic sclerosis: a cross-sectional survey

OBJECTIVE

To assess patient priorities concerning disability in systemic sclerosis (SSc).

METHODS

A total of 150 SSc patients (22 men) fulfilling the American College of Rheumatology and/or LeRoy and Medsger criteria for SSc were evaluated by the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), Karnofsky performance status (KPS), Cochin Hand Function Scale, Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale, Mouth Handicap in SSc (MHISS) scale, and global perception regarding their health status. Correlations between scores were analyzed using Spearman's coefficient. Logistic regression analysis was used to determine factors associated with patients' global perception of their health.

RESULTS

Of the patients investigated, 81 (54%) had limited cutaneous SSc, 65 (43.3%) diffuse SSc, and 4 (2.7%) limited SSc. The 3 disability domains most often cited were walking (82 patients [54.6%]), housekeeping (67 patients [44.6%]), and sport activities (59 patients [39.3%]). The MACTAR score correlated moderately with KPS (r = 0.58) but only weakly with the HAQ score (r = 0.38). In multivariate analysis, 2 factors were associated with patients' negative global perception of their health status: KPS (odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.00-1.15) and MHISS score (OR 0.93, 95% CI 0.88-0.99).

CONCLUSION

For assessing SSc patient priorities concerning disability, the MACTAR has acceptable construct validity. Its weak correlation with the HAQ suggests that it adds useful information on disability.

Prediction of patient survival by healthcare professionals in a specialist palliative care inpatient unit: a prospective study

Accurate prognostication is an enormous challenge for professionals caring for patients with advanced disease. Few studies have compared the prognostic accuracy of different professional groups within a hospice setting. The aim of this study was to compare the ability of 5 professional groups to estimate the survival of patients admitted to a specialist palliative care unit. No group accurately predicted the length of patient survival more than 50% of the time. Nursing and junior medical staff were most accurate while care assistants were least accurate. When in error, senior clinical staff tended to under-estimate survival. Independent mobility on admission was the only variable predictive of length of survival. Thus, professional groups differ in their prognostic accuracy. An awareness of a group's propensity to over- or under-estimate prognosis should be incorporated into future work on prognostication models.

Assessing 2-month clinical prognosis in hospitalized patients with advanced solid tumors

PURPOSE

The aim of this study was to assess clinical, laboratory, and subjective (patient's preferences) prognostic factors in hospitalized patients with advanced solid tumors.

PATIENTS AND METHODS

This prospective study surveyed 177 patients from two French hospitals who had not reached the stage of active dying but had an estimated survival of less than 6 months (median survival, 58 days).

RESULTS

Univariate analysis showed that 10 of the 13 clinical and laboratory factors reported in the literature affected survival at 2 months. Poor prognostic factors were number of metastatic sites, cerebral metastasis, low Karnofsky index, dyspnea at rest, anorexia, edema, confusion, low serum albumin, extremely high leukocyte counts, and high lactate dehydrogenase (LDH) levels. The patient's desire to continue curative treatment was also associated with survival. The multivariate analysis selected four independent criteria: Karnofsky index (in three classes: <or= 30%, 40% to 60%, or >or= 70%), number of metastatic sites (>or= two or < two), low serum albumin (in three classes: <or= 24, 24 to 33, and >or= 33 g/L), and LDH concentration (>or= 600 IU or < 600 IU). The combination of these four criteria assessed prognosis better than the Karnofsky index alone, producing three prognostic profiles: one with short survival (< 2 months: no patient survived to 4 months); one with an expectation of intermediate survival (25% were alive at 4 months), and a final group surviving for several months (80% were alive at 4 months).

CONCLUSION

The prognostic profiles defined by combinations of these four factors may be potentially useful but need further validation before their application in the daily practice.

Predicting survival in patients with advanced disease

Prognostication is an important clinical skill for all clinicians, particularly those clinicians working with patients with advanced cancer. However, doctors can be hesitant about prognosticating without a fundamental understanding of how to formulate a prognosis more accurately and how to communicate the information with honesty and compassion. Irrespective of the underlying type of malignancy, most patients with advanced cancer experience a prolonged period of gradual decline (months/years) before a short phase of accelerated decline in the last month or two. The main indicators of this final phase are poor performance status, weight loss, symptoms such as anorexia, breathlessness or confusion and abnormalities on laboratory parameters (e.g. high white cell count, lymphopaenia, hyopalbuminaemia, elevated lactate dehydrogenase or C-reactive protein). The clinical estimate of survival remains a powerful independent prognostic indicator, often enhanced by experience, but research has only begun to understand the different biases affecting clinicians' estimates. More recent research has shown probabilistic predictions to be more accurate than temporal predictions. Simple, reliable and valid prognostic tools have been developed in recent years that can be used readily at the bedside of terminally ill cancer patients. The greatest accuracy occurs with the use of a combination of subjective prognostic judgements and objective validated tools. Communicating survival predictions is an important part of cancer care and guidelines exist for improving delivery of such information. Important cultural differences may influence communication strategies and should be recognised in clinical encounters. More well-designed studies of prognosis and its impact on decision making are needed. The benefits and limitations of prognostication should be considered in many clinical decisions.

Quality-of-life assessment in palliative care

Quality-of-life assessment can be a helpful tool in ensuring optimal palliative care. To adequately assess quality of life, it must be first defined and subsequently measured. This article outlines several of the instruments available to measure quality of life, including the Karnofsky Score, Edmonton Symptom Assessment, Memorial Symptoms Assessment Scale, European Organization for Research and Treatment of Cancer Questionnaire, Quality and Quantity of Life Short Questionnaire, and Cambridge Palliative Assessment Schedule. Use of these instruments in the context of goal-setting and family meetings as well as common pitfalls in quality-of-life assessment are outlined.

Survival Prediction in Terminally Ill Cancer Patients by Clinical Estimates, Laboratory Tests, and Self-Rated Anxiety and Depression

Purpose

To study how survival of palliative cancer patients relates to subjective prediction of survival, objective prognostic factors (PFs), and individual psychological coping.

Patients and Methods

Survival was estimated according to three categories (< 1 month, 1 to 6 months, and > 6 months) by two physicians (A and B) and the institutional tumor board (C) for 216 patients recently referred for palliative radiotherapy. After 6 months, the accuracy of these estimates was assessed. The prognostic relevance of clinical symptoms, performance status, laboratory tests, and self-reported emotional distress (Hospital Anxiety and Depression Scale) was investigated.

Results

In 61%, 55%, and 63% of the patients, prognoses were correctly estimated by A, B, and C, respectively. κ statistic showed fair agreement of the estimates, which proved to be overly optimistic. Accuracy of the three estimates did not improve with increasing professional experience. In particular, the survival of 96%, 71%, and 87% of patients who died in less than 1 month was overestimated by A, B, and C, respectively. On univariate analysis, 11 of 27 parameters significantly affected survival, namely performance status, primary cancer, fatigue, dyspnea, use of strong analgesics, brain metastases, leukocytosis, lactate dehydrogenase (LDH), depression, and anxiety. On multivariate analysis, colorectal and breast cancer had a favorable prognosis, whereas brain metastases, Karnofsky performance status less than 50%, strong analgesics, dyspnea, LDH, and leukocytosis were associated with a poor prognosis.

Conclusion

This study revealed that physicians' survival estimates were unreliable, especially in the case of patients near death. Self-reported emotional distress and objective PFs may improve the accuracy of survival estimates.

The desire for hastened death in patients with metastatic cancer

A substantial minority of patients in palliative care settings report a high desire for hastened death (DHD), in association with physical and emotional distress, low social support, and impaired spiritual well being. To clarify to what extent DHD emerges in association with suffering prior to the end of life, we determined its prevalence and correlates in ambulatory patients with metastatic cancer, the majority of whom had an expected survival of >6 months. We hypothesized that DHD in this sample would be directly linked to physical and psychological distress, and inversely related to perceived social support, self-esteem, and spiritual well being. Three hundred twenty-six outpatients completed the Schedule of Attitudes Toward Hastened Death (SAHD), Brief Pain Inventory, Memorial Symptom Assessment Scale, Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Medical Outcomes Study Social Support Survey, FACIT-Spiritual Well-Being Scale, Rosenberg Self-Esteem Scale, and Karnofsky Performance Status. Over 50% of participants reported pain, >20% reported elevated levels of depression (BDI-II> or =15) and hopelessness (BHS> or =8), but <2% had a high DHD (SAHD> or =10). DHD was correlated positively with hopelessness, depression, and physical distress, and negatively with physical functioning, spiritual well being, social support, and self-esteem; it was not associated with treatment status or proximity to death. Over 34% of the variance in predicting SAHD scores was accounted for by hopelessness, depression, and functional status. The relative absence of a strong DHD in this sample suggests that the will to live tends to be preserved in cancer patients prior to the end of life, in spite of significant emotional and physical suffering.

A prognostic model for 1-year mortality in older adults after hospital discharge

PURPOSE

To develop and validate a prognostic index for 1-year mortality of hospitalized older adults using standard administrative data readily available after discharge.

SUBJECTS AND METHODS

The prognostic index was developed and validated retrospectively in 6382 older adults discharged from general medicine services at an urban teaching hospital over a 4-year period. Potential risk factors for 1-year mortality were obtained from administrative data and examined using logistic regression models. Each risk factor associated independently with mortality was assigned a weight based on the odds ratios, and risk scores were calculated for each patient by adding the points of each independent risk factor present. Patients in the development cohort were divided into quartiles of risk based on their final risk score. A similar analysis was performed on the validation cohort to confirm the original results.

RESULTS

Risk factors independently associated with 1-year mortality included: aged 70 to 74 years (1 point); aged 75 years and greater (2 points); length of stay at least 5 days (1 point); discharge to nursing home (1 point); metastatic cancer (2 points); and other comorbidities (congestive heart failure, peripheral vascular disease, renal disease, hematologic or solid, nonmetastatic malignancy, and dementia, each 1 point). In the derivation cohort, 1-year mortality was 11% in the lowest-risk group (0 or 1 point) and 48% in the highest-risk group (4 or greater points). Similarly, in the validation cohort, 1-year mortality was 11% in the lowest risk group and 45% in the highest-risk group. The area under the receiver operating characteristic curve was 0.70 for the derivation cohort and 0.68 for the validation cohort.

CONCLUSION

Reasonable prognostic information for 1-year mortality in older patients discharged from general medicine services can be derived from administrative data to identify high-risk groups of persons.

Prognostic significance of symptoms of hospitalised advanced cancer patients

PURPOSE

To assess the prognostic value of symptoms in hospitalised advanced cancer patients.

PATIENTS AND METHODS

A prospective analysis was performed of 181 hospitalised patients referred to a Palliative Care Team. Comprehensive symptom questionnaire, functional status, estimated life expectancy and survival were assessed. Using a Cox regression model, a predictive survival model was built.

RESULTS

Median survival: 53 d. Median number of symptoms: 4; 20 symptoms occurred in 10%. Multivariate analysis showed nausea, dysphagia, dyspnoea, confusion and absence of depressed mood as independent prognostic factors for survival (p<0.05) with relative risks of dying of 1.96, 1.81, 1.79, 2.35 and 1.79, respectively. Patients with 2, 3 or 4 of these factors at the same time had a relative risk of dying of 2.7, 2.1 and 9.0, respectively.

CONCLUSION

A cluster of factors comprising nausea, dysphagia, dyspnoea, confusion and absence of depressed mood may be used to accurately predict survival in hospitalised advanced cancer patients.

Uric acid as a prognostic factor for survival time: a prospective cohort study of terminally ill cancer patients

The aim of this prospective cohort study was to determine whether serum uric acid level is useful as a predictor of survival in terminally ill cancer patients. One hundred eighteen terminally ill cancer patients, including 63 (53.4%) males, were categorized into four groups by serum uric acid levels and followed up until death or to the end of the study. Cox's proportional hazard model was adopted to evaluate the joint effect of some clinicobiological variables on survival. From an initial model containing 51 variables, a final parsimonious model was obtained by means of a stepwise method. Repetitive dispersion analysis was performed for serum uric acid level in 39 subjects for 3 weeks until death. During the study period, 113 (95.76%) subjects expired, and the median survival time was 14 days. In univariate analysis, survival time of the fourth highest group (> or =7.2mg/dL) was significantly shorter than that of the others (hazard ratio (HR)=2.784, P<0.001). After adjustment for low performance status, moderate to severe pain, prolonged prothrombin time, hypocholesterolemia, and high lactate dehydrogenase (LDH) level, high serum uric acid level (> or =7.2mg/dL) was significantly and independently associated with short survival time (HR=2.637, P=0.001). Serum uric acid levels were also significantly increased between the first and the second week before death. These findings suggest that serum uric acid level can be useful in predicting life expectancy in terminally ill cancer patients.

A demographic and prognostic approach to defining the end of life

Studies examining individuals' preferences reflect a broad consensus that the end of life is a period during which medical care should be different from that in other periods in patients' lives. More specifically, patients, families, and health care providers believe that medical care during this unique period should be home-based and focused on ameliorating patient symptoms through minimally invasive means rather than hospital-based acute care, and focused on extending life through invasive approaches. Of great concern is that other, empirical research shows that there is a large disparity between these preferred types of medical care at the end of life and the actual patterns of medical care that is observed before death, with most patients dying in acute-care hospitals while receiving invasive therapies. Without prospective recognition of this period, medical care cannot be appropriately changed. Existing research suggests that there are few clinical tools available to health care providers to aid in making prognostic estimates. Opportunities for future research include efforts to improve the prospective identification of the end of life and communication about the end of life. Specifically, development of valid and reliable predictive algorithms to help patients, families, and health care providers to identify the beginning of the end of life would be welcomed and should ideally be focused at the population level to ensure wide applicability. Similarly, research that works to improve communication between patients and health care providers on the matter of prognosis is also needed.

The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]

BACKGROUND

The Karnofsky Performance Status (KPS) is a gold standard scale. The Thorne-modified KPS (TKPS) focuses on community-based care and has been shown to be more relevant to palliative care settings than the original KPS. The Australia-modified KPS (AKPS) blends KPS and TKPS to accommodate any setting of care.

METHODS

Performance status was measured using all three scales for palliative care patients enrolled in a randomized controlled trial in South Australia. Care occurred in a range of settings. Survival was defined from enrollment to death.

RESULTS

Ratings were collected at 1600 timepoints for 306 participants. The median score on all scales was 60. KPS and AKPS agreed in 87% of ratings; 79% of disagreements occurred within 1 level on the 11-level scales. KPS and TKPS agreed in 76% of ratings; 85% of disagreements occurred within one level. AKPS and TKPS agreed in 85% of ratings; 87% of disagreements were within one level. Strongest agreement occurred at the highest levels (70-90), with greatest disagreement at lower levels (< or =40). Kappa coefficients for agreement were KPS-TKPS 0.71, KPS-AKPS 0.84, and AKPS-TKPS 0.82 (all p < 0.001). Spearman correlations with survival were KPS 0.26, TKPS 0.27 and AKPS 0.26 (all p < 0.001). AKPS was most predictive of survival at the lower range of the scale. All had longitudinal test-retest validity. Face validity was greatest for the AKPS.

CONCLUSION

The AKPS is a useful modification of the KPS that is more appropriate for clinical settings that include multiple venues of care such as palliative care.

Prognostic factors in advanced cancer patients: evidence-based clinical recommendations--a study by the Steering Committee of the European Association for Palliative Care

PURPOSE

To offer evidence-based clinical recommendations concerning prognosis in advanced cancer patients.

METHODS

A Working Group of the Research Network of the European Association for Palliative Care identified clinically significant topics, reviewed the studies, and assigned the level of evidence. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. A systematic electronic literature search within the main available medical literature databases was performed for each of the following four areas identified: clinical prediction of survival (CPS), biologic factors, clinical signs and symptoms and psychosocial variables, and prognostic scores. Only studies on patients with advanced cancer and survival < or = 90 days were included.

RESULTS

A total of 38 studies were evaluated. Level A evidence-based recommendations of prognostic correlation could be formulated for CPS (albeit with a series of limitations of which clinicians must be aware) and prognostic scores. Recommendations on the use of other prognostic factors, such as performance status, symptoms associated with cancer anorexia-cachexia syndrome (weight loss, anorexia, dysphagia, and xerostomia), dyspnea, delirium, and some biologic factors (leukocytosis, lymphocytopenia, and C-reactive protein), reached level B.

CONCLUSION

Prognostication of life expectancy is a significant clinical commitment for clinicians involved in oncology and palliative care. More accurate prognostication is feasible and can be achieved by combining clinical experience and evidence from the literature. Using and communicating prognostic information should be part of a multidisciplinary palliative care approach.

Identification of patients with noncancer diseases for palliative care services

Objective: To identify criteria for measuring the eligibility of patients with end-stage noncancer diseases for palliative care services in Australian residential aged care facilities.

Methods: No validated set if guidelines were available so five instruments were used: an adaptation of the American National Hospice Association Guidelines; a recent adaptation of the Karnofsky Performance Scale; the Modified Barthel Index; the Abbey Pain Score for assessment of people who are nonverbal and a Verbal Descriptor Scale, also for pain measurement. In addition, nutritional status and the presence of other problematic symptoms and their severity were also sought.

Results: The adapted American National Hospice Association Guidelines provided an initial indicative framework and the other instruments were useful in providing confirmatory data for service eligibility and delivery.

[Clinical impressions of terminal cancer patients as an estimator of time of survival]

OBJECTIVE

To evaluate the relationship between the prognosis of the survival time of terminal cancer patients by doctors and nurses belonging to a Home Care Support Team (HCST) and the actual time of survival found. The first assessment and the last before death were examined.

DESIGN

Prospective, descriptive study.

SETTING

Area 7 of primary care, Madrid.

PARTICIPANTS

Were terminal cancer patients attended by the HCST between February 2001 and August 2002.

MAIN MEASUREMENTS

Age, sex, location of the tumour, presence of metastasis, number and location of metastases, real survival time and the time estimated by the doctor and nurse at the first assessment and at the last before death. The quotient of survival time found/survival time estimated was calculated. If it was between 0.67 and 1.33, the prediction was considered correct; < 0.67, optimistic, and >1.33, pessimistic.

RESULTS

121 patients were studied, 57% men, with an average age of 72 +/- 12.8 years. At the first assessment, 30% of doctors' predictions were correct, 40% optimistic and 30% pessimistic. Of nurses' predictions, 40% were correct, 30% optimistic and 30% pessimistic. The intra-class correlation coefficients (ICC) between real and estimated survival times were 0.64 for doctors and 0.54 for nurses. At the final assessment, doctors had 38% correct predictions, 44% optimistic and 18% pessimistic; and nurses had 44% correct, 32% optimistic and 24% pessimistic. The ICCs were 0.83 and 0.84.

CONCLUSIONS

The accuracy of professionals' clinical impression was only acceptable at the moment of quantifying the prognosis.

Development of a prognostic index in cancer patients with low performance status

BACKGROUND

Prognosis is a very important medical function. In advanced cancer it is also important to help planning the care to deliver to individual patients with more accuracy, in the process of decision about the opportunity for some interventions and in the selection of patients for clinical trials. Although the performance status indexes are by themselves prognostic factors, among patients in all stages there are wide variations in survival. In what concerns bedridden patients, survival varies between hours and months. Therefore it would be useful to develop a method which could allow a more precise estimation of the length of survival in these patients.

PATIENTS AND METHODS

We have studied prospectively 110 bedridden patients exploring six variables: consciousness level, recognition of familiar people, continence and capacity to communicate, to eat and to swallow. Each factor was scored on a scale of 0 to 2. Our aim was to construct a classification system with the sum of the scores of the variables significantly correlated with survival. The cut-off-points were calculated using the percentiles < or =25, 50 and > or =75 according to the method of Altman et al. (J Natl Cancer Inst 86:829-835. 1994).

RESULTS

Four of the variables were significantly associated with survival, and an index with three stages was constructed with the sum of these four variables: I-0 to 3; II-4 to 6; III-7 to 8. The differences in survival among the stages are statistically significant and the probability of survival at the 7th, 30th, 60th, and 90th days is also different.

CONCLUSION

The differences in survival observed among the stages can be clinically relevant to the establishment of a prognostic to individual patients.

Accuracy of survival prediction by palliative radiation oncologists

PURPOSE

To examine the accuracy of survival prediction by palliative radiation oncologists.

METHODS AND MATERIALS

After consultation of cancer patients with metastatic disease for referral of palliative radiotherapy, radiation oncologists estimated the survival of the patients. These were compared with the actual dates of death obtained from the Cancer Death Registry. The time to death from all causes was the outcome. The survival times were measured from the date of the first consultation at the palliative radiotherapy clinics.

RESULTS

Six radiation oncologists provided estimates for 739 patients. Of the 739 patients, 396 were men and 343 were women (median age, 69 years). The median survival of all patients was 15.9 weeks. The mean difference between the actual survival (AS) and the clinician predicted survival (i.e., actual survival minus clinician predicted survival) was -12.3 weeks (95% confidence interval, -15.0 to -9.5) for the entire population. The mean difference was -21.9 weeks when the actual survival was < or =12 weeks, -19.2 weeks when the AS was 13-26 weeks, -9.7 weeks when the AS was 27-52 weeks, and +23.0 weeks when the AS was >52 weeks.

CONCLUSION

In this study, the prediction of survival by radiation oncologists was inaccurate and tended to be overly optimistic.

Prediction of survival in terminal cancer patients in Taiwan: constructing a prognostic scale

We prospectively identified prognostic factors and developed a prognostic scale in 356 Taiwanese terminal cancer patients (training set). Demographic data, severity of symptoms/signs, and survival were statistically analyzed to create the scale, which was tested in another 184 patients (testing set). In the training set, liver and lung metastases, functional performance status, weight loss, edema, cognitive impairment, tiredness, and ascites were independently associated with shorter survival (multivariate analysis). The scale ranged from 0.0 (no altered variables) to 8.5 (maximal alteration for all variables). When scores were < 3.5, 2-week survival was predicted with 0.72 and 0.61 accuracy for the training and testing sets, respectively. With scores < 6.0, 1-week survival was predicted with 0.72 and 0.66 accuracy, respectively. This scale, which includes lung and liver metastases and severity of symptoms/signs, may help in identifying the stage of dying and its corresponding symptoms/signs and also in improving survival prediction in terminal cancer patients.

Outcomes and Characteristics of Patients Discharged Alive from Hospice

OBJECTIVES

To describe outcomes and characteristics of patients discharged alive from hospice.

DESIGN

Prospective cohort study using a telephone survey.

SETTING

Hospices (n=18) participating in the Population-Based Palliative Care Research Network during the 1-year study period.

PARTICIPANTS

English-speaking adults (n=164) who were discharged alive from participating hospices during the 1-year study period.

MEASUREMENTS

Mortality within 6 months of hospice discharge.

RESULTS

Thirty-five percent (n=48) of the 139 patients with known outcomes died within 6 months of hospice discharge, 15 of whom (31%) died without hospice readmission. There were no significant associations between sex (P=.77), length of hospice service (P=.99), diagnosis (P=.73), discharge disposition (P=.54), admission evidence of prognosis of less than 6 months to live (P=.22-.95), Karnofsky score at admission or change between admission and discharge (P=.39, P=.38, respectively), or duration of hospice care after stabilization (P=.83) and mortality within 6 months after hospice discharge. Age (P=.11), discharge Karnofsky score (P=.17), and reason for discharge being improved or stabilized condition (P=.13) trended toward statistical significance. The strongest predictor of mortality after hospice discharge was a report that the patient's condition had worsened (hazard ratio=10.2, 95% confidence interval 4.5-23.4).

CONCLUSION

One-third of patients who were discharged from hospice died within 6 months of hospice discharge, indicating ongoing eligibility for hospice care even under the strictest interpretation of hospice eligibility criteria. Patients who are discharged from hospice care should be evaluated frequently, especially within the first weeks to months after discharge, for changes in status, unmet needs, and potential hospice readmission.

A systematic review of physicians' survival predictions in terminally ill cancer patients

OBJECTIVE

To systematically review the accuracy of physicians' clinical predictions of survival in terminally ill cancer patients.

DATA SOURCES

Cochrane Library, Medline (1996-2000), Embase, Current Contents, and Cancerlit databases as well as hand searching.

STUDY SELECTION

Studies were included if a physician's temporal clinical prediction of survival (CPS) and the actual survival (AS) for terminally ill cancer patients were available for statistical analysis. Study quality was assessed by using a critical appraisal tool produced by the local health authority.

DATA SYNTHESIS

Raw data were pooled and analysed with regression and other multivariate techniques.

RESULTS

17 published studies were identified; 12 met the inclusion criteria, and 8 were evaluable, providing 1563 individual prediction-survival dyads. CPS was generally overoptimistic (median CPS 42 days, median AS 29 days); it was correct to within one week in 25% of cases and overestimated survival by at least four weeks in 27%. The longer the CPS the greater the variability in AS. Although agreement between CPS and AS was poor (weighted kappa 0.36), the two were highly significantly associated after log transformation (Spearman rank correlation 0.60, P < 0.001). Consideration of performance status, symptoms, and use of steroids improved the accuracy of the CPS, although the additional value was small. Heterogeneity of the studies' results precluded a comprehensive meta-analysis.

CONCLUSIONS

Although clinicians consistently overestimate survival, their predictions are highly correlated with actual survival; the predictions have discriminatory ability even if they are miscalibrated. Clinicians caring for patients with terminal cancer need to be aware of their tendency to overestimate survival, as it may affect patients' prospects for achieving a good death. Accurate prognostication models incorporating clinical prediction of survival are needed.

Complexities in prognostication in advanced cancer: "to help them live their lives the way they want to"

Predicting survival and disclosing the prediction to patients with advanced disease, particularly cancer, is among the most difficult tasks that physicians face. With the de-emphasis of prognosis in favor of diagnosis and therapeutics in the medical literature, physicians may have difficulty finding the survival information they need to make appropriate estimates of survival for patients who develop cancer. Quite separate from the challenge of estimating survival accurately, physicians may also find the process of disclosing the prognosis to their patients difficult. Using the vignette of a real patient with advanced cancer who far outlived her physician's prognostic estimate, we discuss clinical issues related to the science of prognosis in advanced cancer and the art of its disclosure.

Quality of life for oncology patients during the terminal period. Validation of the HRCA-QL index

AIM

The evolution of performance status, disability, and quality of life (QL) according to the Hebrew Rehabilitation Center for Aged QL (HRCA-QL) index for cancer patients through their terminal period is described. The assessment of HRCA-QL validity and reliability is also described.

DESIGN

A total of 200 cancer patients were followed up from the onset of their "terminal phase" until they died. Information on symptoms, performance, disability and QL were collected by patient's oncologists in hospital and by their family practitioners and community nurses when the patient was at home. Health measures were: the HRCA-QL index, Karnofsky performance status (KPS) and the Independence in Activities of Daily Living (IADL) index.

RESULTS

The three indices were acceptable for a fair number of patients at the start of the terminal phase. Almost two-thirds had a KPS > or =60. With respect to the IADL index, the patients were independent in five of the six functions, with 80% having a HRCA-QL equal to or greater than 4. The median duration of the terminal period was 59 days. All three indices declined progressively, with marked deterioration in the last 2 weeks. The HRCA-QL index was highly correlated with KPS and the IADL index, had good internal consistency and showed an acceptable test-retest and inter-rater reliability. The HRCA-QL index was reactive to clinical changes.

CONCLUSIONS

All three scales confirmed that terminal patients experience a progressive loss of performance, increase in dependence and deterioration of QL as they approach the end of life. Based in these results, we consider the HTCA-QL index valid for use in terminal cancer patients.

The utilization of physical therapy in a palliative care unit

BACKGROUND

In the supportive oncology and palliative care settings, rehabilitation interventions are often overlooked and underutilized, despite high levels of functional disability in these patients. As a result, little is known about the utilization or effectiveness of rehabilitation interventions in palliative care populations.

OBJECTIVE

To assess the utilization of physical therapy (PT) in a hospital-based palliative care unit, to characterize functional disabilities in patients who received PT, and to identify factors related to functional improvement following a course of PT.

METHODS

Retrospective chart review of 100 patients (mean age 70 years, 97% male) discharged from the Milwaukee Veterans Hospital Palliative Care unit over 15 months. Activities of daily living (ADL) performance scores were recorded on admission, at 2 weeks, and at completion of the PT program and correlated with demographic and disease-related variables.

RESULTS

Thirty-seven patients received a formal PT assessment, and 18 patients underwent PT. The most common functional disabilities in patients who received PT were deconditioning, pain, imbalance, and focal weakness. Ten patients demonstrated improvement in ADL function at 2 weeks. Six patients completed the course of PT. Albumin was significantly correlated with functional improvement. When controlling for albumin, patients with diagnosis of dementia were more likely to show improvement in functional status than patients without a dementia diagnosis.

CONCLUSION

PT assessment and utilization were uncommon in this group. When utilized, PT benefited 56% of patients. Factors related to functional improvement following a PT course were a higher albumin level and a diagnosis of dementia. Prospective trials of PT in palliative care patients are needed to better define response rate and predictors of response.

A predictive model for survival in metastatic cancer patients attending an outpatient palliative radiotherapy clinic

PURPOSE

To develop a predictive model for survival from the time of presentation in an outpatient palliative radiotherapy clinic.

METHODS AND MATERIALS

Sixteen factors were analyzed prospectively in 395 patients seen in a dedicated palliative radiotherapy clinic in a large tertiary cancer center using Cox's proportional hazards regression model.

RESULTS

Six prognostic factors had a statistically significant impact on survival, as follows: primary cancer site, site of metastases, Karnofsky performance score (KPS), and fatigue, appetite, and shortness of breath scores from the modified Edmonton Symptom Assessment Scale. Risk group stratification was performed (1) by assigning weights to the prognostic factors based on their levels of significance, and (2) by the number of risk factors present. The weighting method provided a Survival Prediction Score (SPS), ranging from 0 to 32. The survival probability at 3, 6, and 12 months was 83%, 70%, and 51%, respectively, for patients with SPS <or=13 (n = 133); 67%, 41%, and 20% for patients with SPS 14-19 (n = 129); and 36%, 18%, and 4% for patients with SPS >or=20 (n = 133) (p < 0.0001). Corresponding survival probabilities based on number of risk factors were as follows: 85%, 72%, and 52% (<or=3 risk factors)(n = 98); 68%, 47%, and 24% (4 risk factors)(n = 117); and 46%, 24%, and 11% (>or=5 factors)(n = 180)(p < 0.0001).

CONCLUSION

Clinical prognostic factors can be used to predict prognosis among patients attending a palliative radiotherapy clinic. If validated in an independent series of patients, the model can be used to guide clinical decisions, plan supportive services, and allocate resource use.

Quality of life and length of survival in advanced cancer patients on home parenteral nutrition

BACKGROUND

The use of home parenteral nutrition (HPN) in patients with advanced cancer is controversial because survival is usually short and there are no data regarding the quality of life (QoL).

METHODS

Sixty-nine advanced cancer patients enrolled in a program of HPN in six different Italian centers were prospectively studied as regards nutritional status (body weight, serum albumin, serum transferrin and total lymphocyte count), length of survival and QoL through the Rotterdam Symptom Checklist questionnaire. These variables were collected at the start of HPN and then at monthly intervals. All these patients were severely malnourished, almost aphagic and beyond any possibility of cure.

RESULTS

Nutritional indices maintained stable until death. Median survival was 4 months (range 1-14) and about one-third of patients survived more than 7 months. QoL parameters remained stable till 2-3 months before death.

CONCLUSIONS

HPN may benefit a limited percentage of patients who may survive longer than the time allowed by a condition of starvation and depletion. Provided that these patients survive longer than 3 months, there is some evidence that QoL remains stable for some months and acceptable for the patients.

Prognosis in advanced cancer

When considered with other parameters, prognostic factors of survival in far advanced cancer patients are necessary to enable the doctor, the patient, and his or her relative to choose the most suitable clinical management and care setting. Original studies and literature reviews, albeit with methodologic difficulties, have identified the most important prognostic factors as being: CPS, KPS, signs and symptoms relating to nutritional status (i.e., weight loss, anorexia, dysphagia, xerostomia), other symptoms (dyspnea, cognitive failure) and some simple biologic parameters (serum albumin level, number of white blood cells and lymphocyte ratio). Some authors have weighed the different impact of the most important prognostic factors and have integrated them into prognostic scores for clinical use. Despite the usefulness of these instruments, however, the communication of a poor prognosis is one of the most difficult moments to face in the relationship between doctor and patient.

Physician factors in the timing of cancer patient referral to hospice palliative care

BACKGROUND

Although physicians state that patients ideally should receive hospice care for 3 months before death, the majority of patients survive < 1 month in hospice care. In the current study, the authors attempted to determine whether the attributes of referring physicians were associated with the survival of terminally ill cancer patients in hospice.

METHODS

Using a prospective cohort study design, the authors observed the survival of 326 terminally ill cancer patients who were referred by 258 different physicians to 5 outpatient hospice programs in Chicago. The authors evaluated associations between patient, physician, and patient-physician relationship factors and patient survival.

RESULTS

Of the 326 participating patients, 313 (96%) had known dates of death. For these patients, the median survival was 26 days. Controlling for patient demographic and disease factors, there were several physician factors found to be associated with the length of patient survival after hospice referral. For example, when a physician had referred > or = 2 patients to hospice care in the previous 3 months, the patient survived 17 days longer in hospice compared with those patients whose physician referred fewer patients to hospice. When a physician estimated patient survival accurately (estimate obtained at the time of referral), the patient lived 20 days longer in hospice compared with those patients whose physicians made inaccurate survival estimates. The practice specialty of the physician also was found to be associated with patient survival after hospice referral, with patients referred by general internists and geriatricians living 18 days longer in hospice compared with those patients who were referred by oncologists.

CONCLUSIONS

In the current study, referring physician factors were found to be associated with the survival of terminally ill cancer patients after referral to hospice.

Prognostication in advance cancer: nurses' perceptions of the dying process

PURPOSE/OBJECTIVES

To determine how experienced nurses describe the dying process of patients with advanced cancer.

SAMPLE/SETTING

Fifteen nurses, experienced in the care of patients with advanced cancer, employed by a midsize midwestern hospice or academic inpatient oncology unit.

METHODS

Individual interviews using structured and semi-structured questions. Responses were content-analyzed using Krippendorff's techniques.

MAIN RESEARCH VARIABLE

Dying process in cancer.

FINDINGS

Nurses view the dying process as a weeks-to-months-long, multidimensional process that encompasses physical, psychosocial, and spiritual/existential domains. Impending death is recognized and monitored. Common clinical signs include declining interest in life, increased weakness, somnolence, and changes in respiratory, circulatory, and cognitive status.

CONCLUSIONS

Active (or acute) dying processes are recognized and monitored by nurses; the complexities and patterns of the phenomenon remain unarticulated.

IMPLICATIONS FOR NURSING

Future research could explore both empirical and contextual aspects of acute dying processes. Nurses are in a position to develop useful knowledge about acute dying processes in cancer.

How accurate are physicians' clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients? A systematic review

The purpose of this review was to examine the accuracy of physicians' clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients. A MEDLINE search for English language articles published between 1966 and March 2000 was performed using the following keywords: forecasting/clinical prediction, prognosis/prognostic factors, survival and neoplasm metastasis. Searches in CancerLit, EMBASE, PubMed, the Cochrane Library and reference sections of articles were performed. Studies were included if they concerned adult patients with various cancer histological diagnoses and employed clinical prediction and the readily available clinical parameters. Biochemical and molecular markers were excluded. Grading of the evidence and recommendations was performed. Twelve articles on clinical prediction and 19 on prognostic factors met the inclusion criteria. Clinical prediction tends to be incorrect in the optimistic direction but improves with repeated measurements. Performance status has been found to be most strongly correlated with the duration of survival, followed by the 'terminal syndrome', which includes anorexia, weight loss and dysphagia. Cognitive failure and confusion have also been associated with a shorter life span. Performance status combined with clinical symptoms and the clinician's estimate helps to guide an accurate prediction, as reviewed in an Italian series. There is fair evidence to support using performance status, and clinical and biochemical parameters, in addition to clinicians' judgement to aid survival prediction. However, there is weak evidence to support that clinicians' estimates alone could be specifically employed for survival prediction.