The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

Education in Palliative and End-of-life Care - Oncology

The

ProjectEPEC-O

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EEPPEECC

OO

EEPPEECC

OO Module 8Module 8Clarifying Diagnosis Clarifying Diagnosis

and Prognosisand Prognosis

Module 8Module 8Clarifying Diagnosis Clarifying Diagnosis

and Prognosisand Prognosis

EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

ObjectivesObjectives

Describe the difficulty with Describe the difficulty with prognosticationprognostication

Discuss limitations of current Discuss limitations of current prognostic modelsprognostic models

Apply the 6-step protocol to Apply the 6-step protocol to communicate diagnosis and communicate diagnosis and prognosisprognosis

Describe the difficulty with Describe the difficulty with prognosticationprognostication

Discuss limitations of current Discuss limitations of current prognostic modelsprognostic models

Apply the 6-step protocol to Apply the 6-step protocol to communicate diagnosis and communicate diagnosis and prognosisprognosis

VideoVideo

ImportanceImportance

Most people want to knowMost people want to know

Strengthens physician-patient Strengthens physician-patient relationshiprelationship

Fosters collaborationFosters collaboration

Permits patients, families to plan, Permits patients, families to plan, copecope

Most people want to knowMost people want to know

Strengthens physician-patient Strengthens physician-patient relationshiprelationship

Fosters collaborationFosters collaboration

Permits patients, families to plan, Permits patients, families to plan, copecope

Inaccuracy of prognostication9Inaccuracy of prognostication9

Studies of Clinical Predictions of Survival vs Actual SurvivalStudies of Clinical Predictions of Survival vs Actual Survival

StudyStudy # Patients# Patients Median CPS (days)Median CPS (days) Median AS (days)Median AS (days)

Parkes et alParkes et al11 7171 28 (45-56)28 (45-56) 21 (9-34)21 (9-34)

Evans et alEvans et al22 4242 81 (28-182)81 (28-182) 120 (43-180)120 (43-180)

Heyse-Moore et alHeyse-Moore et al33 5050 56 (33-84)56 (33-84) 14 (7-28)14 (7-28)

Maltoni et alMaltoni et al44 100100 42 (28-56)42 (28-56) 32 (13-63)32 (13-63)

Maltoni et alMaltoni et al55 530530 42 (28-70)42 (28-70) 32 (13-62)32 (13-62)

Oxenham et alOxenham et al66 2121 21 (14-35)21 (14-35) 15 (9-25)15 (9-25)

Maltoni et alMaltoni et al77 451451 42 (21-70)42 (21-70) 33 (14-62)33 (14-62)

Christakis et alChristakis et al88 325325 77 (28-133)77 (28-133) 24 (12-58)24 (12-58)

OverallOverall 1,5911,591 42 (28-84)42 (28-84) 29 (13-62)29 (13-62)

Clinical predictions vs. actual survivalClinical predictions vs. actual survival

Over optimistic by factor of 3 - 5Over optimistic by factor of 3 - 5 Over optimistic by factor of 3 - 5Over optimistic by factor of 3 - 5

Glare P. BMJ. 2003.

Clinical predictions vs. actual survivalClinical predictions vs. actual survival Relationships between predictions Relationships between predictions

and survivaland survival

Actual is 30% less than predictedActual is 30% less than predicted

Survival = predicted Survival = predicted 1 week for 1 week for 25%25%

Predicted Predicted survival + 4 weeks for survival + 4 weeks for 27%27%

Relationships between predictions Relationships between predictions and survivaland survival

Actual is 30% less than predictedActual is 30% less than predicted

Survival = predicted Survival = predicted 1 week for 1 week for 25%25%

Predicted Predicted survival + 4 weeks for survival + 4 weeks for 27%27%

Glare P. BMJ. 2003.

Sources of prognostic informationSources of prognostic information Physician prediction Physician prediction

Stage-specific survival dataStage-specific survival data

Performance statusPerformance status

Signs and symptomsSigns and symptoms

Integrated modelsIntegrated models

Physician prediction Physician prediction

Stage-specific survival dataStage-specific survival data

Performance statusPerformance status

Signs and symptomsSigns and symptoms

Integrated modelsIntegrated models

Sources ofsurvival data . . .Sources ofsurvival data . . .

Stage specific survival curvesStage specific survival curves

Natural history studiesNatural history studies

Randomized trials with a ‘best Randomized trials with a ‘best supportive care’ armsupportive care’ arm

Stage specific survival curvesStage specific survival curves

Natural history studiesNatural history studies

Randomized trials with a ‘best Randomized trials with a ‘best supportive care’ armsupportive care’ arm

Natural history studiesNatural history studies

Cancer typeCancer type NNMedian Median survival survival (Years)(Years)

Actuarial Actuarial 5-year 5-year

survival %survival %

BreastBreast1414 250250 2.72.7 18.418.4

BreastBreast1414 1,0221,022 2.32.3 19.819.8

Head and neckHead and neck1515 808808 0.320.32 00

Performance status and prognosis . . .Performance status and prognosis . . .

Independent prognostic factorIndependent prognostic factor

Karnofsky Performance Score <50: Karnofsky Performance Score <50: survival <8 weekssurvival <8 weeks

Independent prognostic factorIndependent prognostic factor

Karnofsky Performance Score <50: Karnofsky Performance Score <50: survival <8 weekssurvival <8 weeks

Mor V, et al. Cancer. 1984.

. . . Karnofsky Score as predictor of survival. . . Karnofsky Score as predictor of survival

KPSKPS Survival in daysSurvival in days

5050 86.186.1

30-4030-40 49.849.8

10-2010-20 16.816.8

Reuben DB, Mor V, Hiris J. Arch Intern Med. 1988.

SymptomSymptom Median survivalMedian survival

DyspneaDyspnea55 <30 days<30 days

DysphagiaDysphagia55 <30 days<30 days

Confusion/deliriumConfusion/delirium23,2423,24 <28 days<28 days

XerostomiaXerostomia2020 <50 days<50 days

Weight loss (Weight loss (10 kg)10 kg) <28 days<28 days

Clinical signs and symptoms as prognostic indicators in patients with advanced disease

Prognostic impactPrognostic impact

IndexIndex Median survival (Months)Median survival (Months)

HypercalcemiaHypercalcemia 1 - 4.51 - 4.5

Brain metastases Brain metastases plus surgeryplus surgery 9.59.5

Brain metastases Brain metastases without surgerywithout surgery 44

Pleural effusionPleural effusion 33

6-step protocol . . .6-step protocol . . .

1.1. Getting startedGetting started

2.2. Find out what the patient knowsFind out what the patient knows

3.3. Find out how much the patient Find out how much the patient wants to knowwants to know

1.1. Getting startedGetting started

2.2. Find out what the patient knowsFind out what the patient knows

3.3. Find out how much the patient Find out how much the patient wants to knowwants to know

Adapted from Robert Buckman

Communicating prognosis . . .Communicating prognosis . . .

Some patients want to planSome patients want to plan

Others are seeking reassuranceOthers are seeking reassurance

Some patients want to planSome patients want to plan

Others are seeking reassuranceOthers are seeking reassurance

. . . Communicating prognosis . . .. . . Communicating prognosis . . . Limits of predictionLimits of prediction

Hope for the best, plan for the worstHope for the best, plan for the worst

Better sense over timeBetter sense over time

Can’t predict surprises, get affairs in Can’t predict surprises, get affairs in orderorder

Reassure availability, whatever Reassure availability, whatever happenshappens

Limits of predictionLimits of prediction

Hope for the best, plan for the worstHope for the best, plan for the worst

Better sense over timeBetter sense over time

Can’t predict surprises, get affairs in Can’t predict surprises, get affairs in orderorder

Reassure availability, whatever Reassure availability, whatever happenshappens

. . . Communicating prognosis . . . . . . Communicating prognosis . . .

Inquire about reasons for askingInquire about reasons for asking

““What are you expecting to happen?”What are you expecting to happen?”

““How specific do you want me to be?”How specific do you want me to be?”

““What experiences have you had with:What experiences have you had with:

others with same illness?”others with same illness?”

others who have died?”others who have died?”

Inquire about reasons for askingInquire about reasons for asking

““What are you expecting to happen?”What are you expecting to happen?”

““How specific do you want me to be?”How specific do you want me to be?”

““What experiences have you had with:What experiences have you had with:

others with same illness?”others with same illness?”

others who have died?”others who have died?”

. . . 6-step protocol. . . 6-step protocol

4.4. Share the informationShare the information

5.5. Respond to patient, family feelingsRespond to patient, family feelings

6.6. Plan, follow-upPlan, follow-up

4.4. Share the informationShare the information

5.5. Respond to patient, family feelingsRespond to patient, family feelings

6.6. Plan, follow-upPlan, follow-up

Adapted form Robert Buckman

. . . Communicating prognosis. . . Communicating prognosis Patients varyPatients vary

‘‘Planners’ want more detailsPlanners’ want more details

Those seeking reassurance want lessThose seeking reassurance want less

Avoid precise answersAvoid precise answers

Hours to days. . .months to yearsHours to days. . .months to years

AverageAverage

Patients varyPatients vary

‘‘Planners’ want more detailsPlanners’ want more details

Those seeking reassurance want lessThose seeking reassurance want less

Avoid precise answersAvoid precise answers

Hours to days. . .months to yearsHours to days. . .months to years

AverageAverage

SummarySummary

Prognostication is inexactPrognostication is inexact

Karnofsky performance status is an Karnofsky performance status is an important prognostic factorimportant prognostic factor

In advanced (<3 months) disease, In advanced (<3 months) disease, symptoms predict prognosissymptoms predict prognosis

Prognosis is difficult to define for Prognosis is difficult to define for patients with survival >6 monthspatients with survival >6 months

Prognostication is inexactPrognostication is inexact

Karnofsky performance status is an Karnofsky performance status is an important prognostic factorimportant prognostic factor

In advanced (<3 months) disease, In advanced (<3 months) disease, symptoms predict prognosissymptoms predict prognosis

Prognosis is difficult to define for Prognosis is difficult to define for patients with survival >6 monthspatients with survival >6 months