Supported by evidence-based data, this webinar helps clinicians identify hospice-eligible patients with advanced cancer, cardiac disease, lung disease, dementia, liver disease, stroke, and HIV/AIDS.

1. Determining Prognosis in
Cancer and Non-Cancer
Diagnoses

2. 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 Illinois are provided CE credit for their Nursing
Home Administrators and Respiratory Therapists through: VITAS Healthcare
Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA
CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved
By the Illinois Division of Profession Regulation for: Licensed Nursing Home
Administrators and Illinois Respiratory Care Practitioner.
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: 06/06/2018 – 06/06/2021. Social workers completing this course
receive 1.0 ethics 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 01/31/2023.
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
01-2019

3. 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.

4. 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

5. “Medicine is a science of uncertainty
and an art of probability.”
—Sir William Osler

6. Prognosis
and Practice
of Medicine
• What to expect from an individual’s
disease course
• Clinicians’ prognostic estimates
provide a framework to make
informed decisions about care
– Health screening
– Disability outcomes
– Disease management
– Advance care planning
– End-of-life decisions including
hospice enrollment

7. Medicare
Hospice
Benefit
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 Benefit Policy Manual (Rev. 246, 09-14-18).

8. Medicare
Hospice
Benefit
(cont.)
Benefits Protection and Improvement
Act (BIPA) 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.”

9. 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.

10. Theoretical
Trajectories
of Dying
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.

11. General
Domains to
Consider
• Clinical judgment
• Nutrition
• Physical function
• Cognition
• Healthcare utilization
• Symptoms

12. Clinical
Judgment
Would you be surprised if this patient
were to die in the next year?

13. Surprise
Question
• Would you be surprised if this patient
were to die in the next year?
• Recent meta-analysis
– Sensitivity 67.0% (55.7%–76.7%)
– Specificity 80.2% (73.3%–85.6%)
– PPV 37.1% (30.2%–44.6%)
– NPV 93.1% (91.0%–94.8%)
– AUC 0.81 (95% CI 0.78–0.86)
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.

14. Nutritional
Status
• Albumin level
• Choking and/or
pocketing food
• Wounds
• Muscle wasting
– Sarcopenia
– Temporal wasting
• Weight change
– ≥ 10% of normal
body weight in
6 months
– ≥ 5% of normal
body weight in
1 month
• BMI change
(BMI < 22)

15. Weight
Loss and
Prognosis
Long-Term Care
• 153 residents,
24 lost 5% weight
in 1 month
• 5.1 times more
likely to die in
1 year
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.
Outpatient
• Prospective evaluation
of 91 patients with
weight loss
• 35% no identifiable
cause
• 25% died over
the ensuing year

16. Dysphagia
and Survival
Mortality with
dysphagia:
30-day: 22.9%
1-year: 55.4%
Cabre, M., et al. (2010). Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing, 39:39-45.

17. 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

18. 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

19. Palliative Performance Scale
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!
Anderson, F., et al. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1):5-11.
Generally Hospice
Eligible

20. 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.

21. 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.

22. 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

23. 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 the bed prior to death, and number of days in bed increases.

24. 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
0
4
8
12
16
20
24
28
32
0 1 2 3 4 5 6 7 8 9 10 11 12
Number
of
Deaths
Months After Index Fall
Cumulative mortality in 125 fallers and 125 controls in 12 months after index fall.
Fallers
Controls

25. 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

26. 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.

27. Increased
Healthcare
Utilization
• Clinic visits
• Subspecialty visits
• Emergency department visits
• Hospitalizations

28. 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

29. Uncontrolled
Symptoms
• Pain
• Shortness of breath
• Delirium
• Agitation
• Nausea and vomiting
• Constipation
• Exhaustion, fatigue, low activity

30. 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.
6
Months
12
Months
18
Months
36
Months
Delirium 37.7 44.3 51 58.4
2-CAM 36.1 41.8 41.8 50.5

31. Indicators of Poor Prognosis
in Cancer and Non-Cancer
Diagnoses

32. Function
Death is more
predictable
Low
Onset of illness
High
Decline usually 3-6 month
Cancer
Trajectory
Slower trajectory for hormone-sensitive tumors,
i.e., breast, prostate
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.
Functional Status: Key Determinant Prognosis
ECOG 3: 50% of time in bed
or chair; hospice eligible

33. Cancer, Function, and Prognosis
Jang, R., et al. (2014). Simple prognostic model for patients with advanced cancer based on performance status. American Society of Clinical Oncology.
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.

34. 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

35. Heart Failure
Trajectory
Function
Low
High
NYHA Class III/IV
Hospice Eligible
Death
NYHA Symptoms:
Shortness of breath • Fatigue
Chest pain • Palpitations
NL and low EF maintain a similar trajectory and prognosis
Multiple Hospitalizations Death After Exacerbation
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.

36. HF and
Prognosis
by Ejection
Fraction
Miyagishima, K., et al. (2009). Long term prognosis of chronic heart failure reduced vs
preserved left ventricular ejection fraction. Circulation Journal, 73: 92–99.
Reduced vs. Preserved EF

37. 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%

38. 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
Significant disease
Occasional
assistance
necessary
Normal
or
reduced
Full
or
confusion
50
Mainly
sit/lie
Unable to do
any housework
Extensive disease
Considerable
assistance
required
40
Mainly
in bed
Unable to do
most activities
Extensive disease
Mainly assistance
Full or
drowsy
+/-
confusion
30
Totally
bedbound
Unable to do
any activities
Extensive disease
Requires
total care

39. Heart Failure
and Hospice
• Symptoms with minimal exertion or at rest
(NYHA Class III/IV) despite standard of care
• Inability to tolerate standard-of-care
medical therapies
• Recent history of cardiac arrest or
recurrent syncope
• Inotropic support required and not LVAD/
transplant candidate
• Oxygen requirement secondary to poor
cardiac function
• Cachexia
– Weight loss of 7.5% in 6 months associated
with 29% mortality
• ED visits and hospitalizations from HF exacerbations

40. Function
Death
Low
High
Multiple Hospitalizations Death After Exacerbation
COPD patients often expire
surrounding hospital ICU
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.
Ongoing Lung Function Decline Despite Treatment,
Accompanied by Hospitalizations and Progressive Dyspnea

41. 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

42. COPD and
Hospice
Eligibility
Generally 1 and 2 Present
1. Disabling dyspnea as
demonstrated by:
• Dyspnea at rest or with
minimal exertion on oxygen
• Dyspnea poorly responsive
to bronchodilators
2. Progressive pulmonary
disease as manifested
by any of the following:
• Hospitalizations, ER visits,
or doctor’s office visits
• Recent exacerbation or
infection requiring intubation
• Cor pulmonale
Supportive Features
• Weight loss
• Resting tachycardia
• ADL dependency
• Abnormal tests
(if available)
– pO2 < 55 mmHg
– pCO2 > 50 mmHg
– O2 saturation < 88%
– FEV-1 < 30% predicted,
post-bronchodilator

43. 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.
Compounded Annual Growth Rates by Life-Sustaining Treatment for COPD Patients
with Hospital Deaths
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.

44. Dementia
Trajectory
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
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.

45. Dementias and
Other End-Stage
Neurodegenerative
Disorders
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
Patient experienced one or more of
the following complications in the
last 6 months:
• Febrile episodes
• Altered nutritional
status (weight loss
10% in 6 months)
• Eating difficulty,
including feeding
tube decision
• Hip fracture, with
or without repair
• Delirium

46. Natural History of Dementia
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%

47. Survival After
Acute Illness:
Severe
Dementia vs.
Cognitively
Intact
Hip Fracture
• 6-month mortality
• If impaired: 55%
• If intact: 12%
Morrison, R., et al. (2000). Survival in end-stage dementia following acute illness. JAMA, 284(1):47-52.
Pneumonia
• 6-month mortality
• If impaired: 53%
• If intact: 13%

48. 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.

49. 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

50. End-Stage
Liver Disease
• Laboratory evidence of end-stage
liver disease:
– International Normalized Ratio
(INR) > 1.5
– Serum albumin < 2.5 gm/d1
• Signs of end-stage liver disease:
– Ascites, refractory to treatment,
or patient non-complaint
– Spontaneous bacterial peritonitis
– Hepatorenal syndrome
– Hepatic encephalopathy, refractory
to treatment, or patient non-compliant
– Recurrent variceal bleeding, despite
intensive therapy

51. HIV/AIDS
• CD4+ Count < 25 cells/mcL or persistent
viral load > 100,000 copies/ml
• Plus one of the following:
– CNS lymphoma
– Wasting (loss of 33% lean body mass)
– Mycobacterium avium complex (MAC)
– Progressive multifocal
leukoencephalopathy
– Systemic lymphoma
– Visceral Kaposi’s sarcoma
– Renal failure in the absence
of dialysis
– Cryptosporidium infection
– Toxoplasmosis

52. HIV/AIDS
(cont.)
• Other factors that support eligibility include:
– Decreased performance status, as
measured by the KPS/PPS ≤ 50
– Chronic persistent diarrhea for
1 year
– Albumin < 2.5
– Concomitant, active substance abuse
– Age > 50 years
– Absence of drug therapy related
specifically to HIV disease
– Advanced AIDS dementia complex
– Congestive heart failure, symptomatic
at rest

53. ESRD
Spending
Trajectories
in the Last
Year of Life:
2000-2014
O’Hare, A., et al. (2018). Hospice use and end-of-life spending trajectories in
Medicare beneficiaries on hemodialysis. Health Affairs, 37:980–987.
41%
Group 1
13%
Group 2
Group 4
37%
Group 3
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
Quarter 1 Quarter 2 Quarter 3 Quarter 4
9%

54. 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.
Intensity of Care Dialysis Cancer
Hospitalization 76% 61.3%
Days Hospitalized 9.8 5.1
ICU Admission 48.9% 24.0%
Days in ICU 3.5 1.3
Any Intensive Procedure 29% 9%
Hospice Use 20% 55%
Died in Hospital 44.8% 29.0%
Last Month
of Life: ESRD
and Cancer

55. 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.

56. 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.

57. 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
12
9
6
3
Residents (%)
Months
Since
Initiation
of
Dialysis
Died Functional status decreased Functional status maintained

58. 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)

59. 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
VITAS®
Healthcare ESRD Care Considerations
for Patients Receiving Dialysis
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.

60. 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

61. Questions?

62. References
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.

63. References
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.
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.
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.

64. References
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).
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

65. References
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. Clinical Journal of the American Society
of Nephrology, 8(12):2117-2122.
O’Hare, A., et 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.
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.

66. References
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.