John Thomas

Date of Award

January 2012

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Terri R. Fried

Subject Area(s)

Gerontology, Aging

Abstract

FORETELLING THE FUTURE OF PROGNOSTICATION: A HISTORICALLY INSPIRED DOMAIN-BASED APPROACH FOR THE ELDERLY

John M. Thomas and Terri R. Fried. Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.

Hypothesis: 1) Physicians' decisions to discuss hospice as an option for terminally ill patients are based on a limited approach to prognostication that excludes many patients who may benefit from discussions. 2) Identifying broader domains of health most important for prognostication, as an alternative to calculating life expectancy or mortality risk, might encourage prognostication and improve physician-patient communication.

Aims: 1) To examine the association between physicians' prognostic assessments and their discussion with patients about hospice. 2) To identify the domains of health-related characteristics of older hospitalized patients and nursing home residents most strongly associated with short-term mortality.

Methods: Following an historical introduction on prognostication, we describe two empiric studies. First, we performed secondary analyses of surveys administered to 215 patients age 60 years or greater with advanced cancer, chronic obstructive pulmonary disease, or heart failure that were performed at least every 4 months for up to 2 years, as well as surveys to their respective physicians at least every 6 months. Then we performed a systematic review of prospective studies that evaluated the association between at least one health-related patient characteristic and mortality within one year among patients age 65 years or greater. All studies published in English in MEDLINE, Scopus, or Web of Science before August 1, 2010 were eligible. We categorized the characteristics into a series of domains. Using the results of multivariable analyses, we ranked domains within each study according to strength of association with mortality, then calculated the overall relative strength of each domain as compared to other domains across studies.

Results: Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion in our empiric analysis were physicians' estimate of and certainty about patient life expectancy (P<0.001). That said, physicians did not anticipate the deaths of 40% of patients. In the systematic review, we classified characteristics associated with mortality from forty-eight studies into seven domains: cognitive function, disease diagnosis, laboratory values, nutrition, physical function, pressure sores, and shortness of breath. The most important domains for prognostication were nutrition and shortness of breath among general nursing home residents; physical function and shortness of breath among nursing home residents with dementia; disease diagnosis, nutrition, and pressure sores among hospitalized patients for in-hospital mortality; and physical function and nutrition among hospitalized patients for mortality up to one year.

Conclusions: Clinicians' discussion of hospice for patients with advanced illness relies largely on a highly unreliable prognostic approach that involves estimated life expectancy, and many clinicians whose patients might benefit from learning about hospice are not having these discussions. Among a large number of health-related characteristics of older persons shown to be associated with short-term mortality, a few consistently important domains provide broad, easily measurable factors that may promote an approach to prognostication that simply alerts physicians to patients who are at increased risk for mortality, rather than aiming for certainty in life expectancy, thus encouraging physician-patient communication for elderly persons nearing the end of life.

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