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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.