Download Appropriate timing of Palliative care in non

Appropriate timing of Palliative care
in non-malignant diseases
대한가정의학회 추계학술대회
완화의학연구회 세미나
2010년 11월 7일
청주 하나병원 가정의학과
김정현
Palliative care(WHO)
• 생명을 위협하는 질환에 의한 문제에 직면한
환자와 가족의 삶의 질을 향상 시키기 위해
통증을 비롯한 다른 증상들과 신체적, 정신적
문제를 조기에 발견하고 평가하여 그들의 고
통을 미연에 예방하거나 덜어주기 위한 의료
J Pain Symptom Manage 2002;24:91-6
보건복지부
• 환자의 전신상태가 악화되는 말기 암환자
• 적극적인 항암치료의 시행이 환자의 경과에 더 이상 도움을
줄 수 없다고 판단되는 경우
• 예상되는 기대여명이 6개월 미만
• 환자와 가족이 환자의 진단과 예후를 알고 있는 경우
• 환자와 가족이 완화 의학적인 지지적 의료를 희망하는 경우
• 지난 3개월간 적어도 2회 이상 응급실을 방문하였거나, 병원
에 입원한 경우
The Older “Transition”
Model of Care
a “Trajectory” Model
Lynn J, Adamson DM. 2003
USA
2009 National Consensus Project for Quality Palliative Care
CLINICAL PRACTICE GUIDELINES FOR QUALITY PALLIATIVE CARE, 2nd Ed.
USA
ratio
malignancy
non-malignancy
38%
62%
J Pain Symptom Manage 2009;38(1):105-9.
National Hospice and Palliative
Care Organization (NHPCO)
The patient should meet all of the following criteria:
I. The patient’s condition is life limiting, and the patient
and/or family know this
II. The patient and/or family have elected treatment goals
directed toward relief of symptoms, rather than the
underlying disease
III. The patient has either of the following:
JAMA. 2001;285(7):925-932
A. Documented clinical progression of the disease,
which may include:
1. Progression of the primary disease process as listed in the
disease-specific criteria, as documented by serial physician
assessment, laboratory, radiologic, or other studies
2. Multiple emergency department visits or inpatient
hospitalizations over the prior 6 months
3. For homebound patients receiving home health services,
nursing assessment may document decline
4. For patients who do not qualify under 1, 2, or 3, a recent
decline in functional status should be documented; clinical
judgment is required
JAMA. 2001;285(7):925-932
B. Documented recent impaired nutritional
status related to the terminal process:
1. Unintentional, progressive weight loss of .10%
over the prior 6 months
2. Serum albumin ,25 g/L may be a helpful
prognostic indicator, but should not be used in
isolation from other factors above
JAMA. 2001;285(7):925-932
Usually, Palliative care
• UK - 95% of patients have a diagnosis of
cancer
• Korea – nearly, 99%
• Palliative care services must be extended
beyond cancer care, this is not yet
common practice.
Addington-Hall J. 1995
Barriers (1) - prognosis
Clipp, Pavalko, and Elder 1992
Short Period of Evident Decline
Ann Intern Med. 2008;148:147-159.
Prolonged Dwindling
Ann Intern Med. 2008;148:147-159.
Long-Term Limitations with Intermittent
Serious Episodes
Ann Intern Med. 2008;148:147-159.
Barriers(2) – acceptability
the attitudes of
potential new users
efforts to extend the
reach of specialist
palliative care.
Soc Sci Med 1999; 48: 1271–80.
Observational cohort study
• 118 community-dwelling persons
• Age ≥65 years with advanced disease
• To determine the association of
preferences with end-of-life care pathway.
J Gen Intern Med 2007. 22(11):1566–71
Care Pathway Having an Initial Goal of Life Prolongation
with Participants’ Preferences and with Diagnosis
Odds ratio
(95% Confidence interval)
Willingness to undergo Intensive treatment
Lower willingness
Reference
Greater willingness
4.73 (1.39,
16.08)
(desires invasive interventions only with ≤10%
likelihood of death)
(desires invasive Interventions despite ≥50%
likelihood of death)
Disease diagnosis
Cancer
Reference
COPD
6.44 (2.27,
18.28)
Heart failure
8.29 (2.85,
24.14)
J Gen Intern Med 2007. 22(11):1566–71
Mismatches between preferences and pathways
Preference
Mismatch (%)
Lower willingness
to undergo intensive treatment
received
1 of 27 (4%)
With highly intensive
Greater willingness
to undergo intensive treatment
53 of 91 (58%)
With symptom control only
J Gen Intern Med 2007. 22(11):1566–71
Other barriers
• Expansion might lead to skills and
funding shortages
Age and Ageing 2005; 34: 218–227
• a lack of research
J R Soc Med 2005;98:503–506
Decision making
Prognosis &
predicted
survival
Palliative
Patient’s
value &
expectation
care
Clinical
expertise
General
PREDICTING SURVIVAL
Palliative Prognostic(PaP) Score
Four clinical items
Dyspnea
anorexia
Karnofsky performance status(KPS)
Clinician's estimate of survival (weeks, CPS)
Two laboratory items
Total white cell count (* 109/L)
Lymphocyte percent (of total WCC)
Risk groups
Total score
A (30 day survival probability > 70%)
0~5.5
B (30 day survival probability 30~70%)
5.6~11
C (30 day survival probability < 30%)
11.5~17.5
Prospective cohort study
•
•
•
•
65 (median age 67 [range 27–92] years; 42 males)
patients with nonmalignant disease
between Jan 2000 and April 2002.
followed-up for 1 year.
J Pain Symptom Manage 2003; 26: 883–5.
Kaplan-Meier survival curves
log-rank test for
trend χ2 with 1
d.f. 39.53,
P 0.0001
J Pain Symptom Manage 2003; 26: 883–5.
Palliative Performance Scale(PPS)
Prospective cohort study
• A total of 466 patients
• Heterogeneous Hospice Population
(including cancer patients)
J Pain Symptom Manage 2003;26(4):883-5.
Kaplan–Meier survival curves by PPS score.
Log rank test
p .001
J Pain Symptom Manage 2003;26(4):883-5.
Area under ROC curve
J Pain Symptom Manage 2003;26(4):883-5.
Index for 1 year mortality
-Walter et al.
• Data analyses derived from 2 prospective
studies
• age>70, discharged from hospital
• with 1-year of follow-up,
• conducted in 1993 through 1997.
– Derivation(n = 1495)
– Validation(n = 1427)
JAMA. 2001;285(23):2987-2994
Risk Factors Associated with 1-Year
Mortality
JAMA. 2001;285(23):2987-2994
Validation of Prognostic Index:
1-Year Mortality in Derivation and Validation
Cohorts by Risk Strata
JAMA. 2001;285(23):2987-2994
Kaplan–Meier survival curves
JAMA. 2001;285(23):2987-2994
Tool
Usefulness
Limitation
PaP score
•Simple measure for
short term survival
•Well validated in
cancer Pts
PPS score
•The most promising
prognostic scale for
use with hospice
patients
Walter et
al.
•problems of recall, computation
•useful for determining
•failure to associate with instructions
1-year survival in older
for appropriate therapeutic or palliative
patients
care
•Weak evidence in older non-cancer
patients
•CPS dependent scale
Age and Ageing 2005; 34: 218–227
Predicting survival
COPD
COPD vs Lung cancer
• Patients with CLD at the end of life have physical
and psychosocial needs at least as severe as patients
with lung cancer.
Palliative Medicine 2001; 15: 287–295
• The patients with COPD had significantly worse
activities of daily living and physical, social, and
emotional functioning than the patients with NSCLC
(p<0.05).
Thorax 2000;55:1000–1006
NHPCO
Pulmonary disease:
I. Severe chronic lung disease, documented by dyspnea at rest, fatigue,
decreased functional ability, or increased exacerbation
II. Cor pulmonale or right heart failure
III. Hypoxemia at rest on supplemental oxygen
IV. Hypercapnia (pCO2.50 mm Hg)
V. Other factors contributing to a poor prognosis:
•unintentional continuing weight loss of 10% body weight over the
preceding 6 months;
•resting tachycardia greater than 100/min
JAMA. 2001;285(7):925-932
6Mo 30-40% mortality
SUPPORT criteria : two of the following for hospitalized patients:
Baseline PaCO2 > 45 mm Hg
Presence of cor pulmonale
FEV1 0.75 liters
Previous episode of respiratory failure in the last 12 months
Am J Respir Crit Care Med 1996;154(4 Pt1):959–967.
Increased risk of death in next 12 months
Emerging Profile of COPD Patients at Risk for Dying of
Respiratory Failure Within 1 Year
Best FEV1 30% of predicted
Declining performance status, with increasing dependence on others for
activities of daily living
Uninterrupted walk distance limited to a few steps
More than one urgent hospitalization within the past year
Left-heart and/or other chronic co-morbid disease
Older age
Depression
Unmarried
Respir Care 2004;49:90–97.
30–40% 2-year mortality(score>6)
BODE index
Points
0
1
2
3
FEV1(% fo predicted)
≥65
50~64
36~49
≤35
Distance walked in
6min(m)
≥350
250~349
150~249
≤149
MMRC dyspnea scale
0-1
2
3
4
Body Mass Index
›21
≤21
MMRC: Modified Medical Research Council score of 3 indicates patient stops for
breath at 100 yards or after a few minutes on level ground, MMRC score of 4: patient
is too breathless to leave the house or is breathless dressing or undressing.
NEngl J Med.2004;350:1005–1012.
Biomarkers
Respiratory Medicine (2010) 104, 773e779
Predicting survival
CONGESTIVE HEART FAILURE
Palliative care: heart failure.
AM J HOSP PALLIAT CARE 2009 26: 399
ACC/AHA STAGING
NEW YORK HEART ASSOCIATION FUNCTIONAL
CLASSIFICATION OF HEART FAILURE
NYHA classification
I
Cardiac disease, but no limitation of physical activity. Ordinary
activity does not cause undue fatigue, dyspnea or anginal pain.
II
Symptom-free at rest. Ordinary activity may cause fatigue,
dyspnea or anginal pain that resolves with rest and results in
only slight limitation of physical activity.
III
Symptom-free at rest. Ordinary activity is markedly limited by
fatigue, dyspnea or anginal pain.
IV
Cardiac disease causes inability to carry out any physical
activity without discomfort. Fatigue, dyspnea or angina may be
present at rest. Any physical activity increases discomfort.
Mortality
per year
5-10%
40-50%
Overall mortality
• Five-year mortality after onset of HF
– Men : aged 65 to 74 is 50%–59%
– Women : 45%.
• 5-year survival following first admission
– worse than that seen in most cancers.
(except lung cancer)
Sudden death
• Most patients whose deaths are caused by advanced
HF die in pump failure.
• The incidence of sudden death rises sharply in the
early stages of HF
• The proportion of sudden deaths
– class II : 50%–80%
– class III : 30%–50%
– class IV : less than 30%.43
NHPCO
Heart disease:
I. Intractable or frequently recurrent symptomatic heart failure, or
intractable angina pectoris with heart failure
II. Patients should already be optimally treated with diuretics and
vasodilators
III. Other factors contributing to a poor prognosis: symptomatic
arrhythmias, history of cardiac arrest and resuscitation or syncope,
cardiogenic brain embolism, or concomitant human immunodeficiency
virus disease
JAMA. 2001;285(7):925-932
Enhanced Feedback for Effective Cardiac Treatment study
(EFFECT)
JAMA. 2003;290(19):2581-2587
EFFECT – 30 days
JAMA. 2003;290(19):2581-2587
EFFECT – 1 year
JAMA. 2003;290(19):2581-2587
Conclusion
• 다양한 비암성 질환의 완화의료 의뢰 시기를 단순히 여명 6개
월 미만으로 정하는 것은 바람직하지 않다.
• 각 질환 별로 개별화된 예측도구를 적용하는 것이 필요하다.
• 생존기간 못지 않게 진단 당시부터 임종에 이르는 기간 동안
의 지속적인 환자의 요구 사항에 주목할 필요가 있다.
• 사회심리학적인 요인이 비암성 질환을 가진 환자들의 생존 기
간과 삶의 질에 미치는 영향에 대한 연구가 더 필요하다.
감사합니다.