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EPM Tools - Stratifying End-of-Life Risk for Hospice Services: Tutorial for SETMA’s Deploymnent of Four Risk Calculators for Hospice Care

Karnosky & Lansky Performance Scales
Palliative Performance Scale for Cancer Patients
Braden Scale Clinically Unavoidable Skin Lesions
Functional Assessment Testing Alzheimer’s and Related Conditions

As end-of-life planning becomes increasingly an important part of patient care, it is important to find ways of quantifying patient’s qualification for hospice care and where possible, a means of quantifying a reliable estimate of survival time for patients. While there will never be an absolute, four scores are being used to aid in this process. The first, the Karnofsky Scale, was first described in 1949; the second, the Palliative Performance Scale has been used in cancer patients since 1996; the third the Braden Clinically Unavoidable Skin lesions and the fourth Functional Assessment Testing Alzheimer’s and Related Conditions (FAST).

SETMA has deployed all four of these scores, along with a fifth which is the Lansky Scare. The Lansky is like the Karnosky Scale but is used with patient under 16. These tools can be found by going to GP Master Template. In the second column you will find these four scales. They are also deployed on the Master Template in the Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Suite of templates.

These only need to be completed in patients you are considering referral to hospice care or palliative care. However, both the Karnofsky and the FAST have value in assessing those patients who are at high risk of readmission.

A Karnofsky score of 60 or less qualifies a patient for referral to hospice. Below, the SETMA’s EMR templates there are more details about both scales.

The Palliative Performance Scale for Cancer Patients is found on the same template. This score’s results are expressed in “survival time from the point of admission to hospice.” The evidence-based literature has only measured this scale in the case of patients with cancer. Further information is found below about this scale.

The Braden Score was developed in 1988 and has been used by SETMA in the Nursing Home patients since 2002. The Braden is based on 6 categories of evaluation and gives a score which indicates whether or not the patient is susceptible to clinically unavoidable skin lesions.

Nursing Home Suite

A tutorial for this assessment can be reviewed under Electronic Patient Management Tools: Nursing Home

The fourth tool is the Functional Assessment Testing (FAST) Alzheimer’s and Related Disorders. This tool is also valuable to use for cognitive functioning of patients with dementia but who are either not hospice eligible or not being considered for hospice.

To be eligible for hospice beneficiaries with Alzheimer’s disease must have a FAST Scale of greater than or equal to 7 FAST Scale Items:

Stage 1: No difficulty, either subjectively or objectively
Stage 2: Complains of forgetting location of objects; subjective work difficulties
Stage 3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations
Stage 4: Decreased ability to perform complex tasks (e.g., planning dinner for guests, handling finances)
Stage 5: Requires assistance in choosing proper clothing
Stage 6: Decreased ability to dress, bathe, and toilet independently;

Sub-stage 6a: Difficulty putting clothing on properly
Sub-stage 6b: Unable to bathe properly; may develop fear of bathing
Sub-stage 6c: Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)
Sub-stage 6d: Urinary incontinence
Sub-stage 6e: Fecal incontinence

Stage 7: Loss of speech, locomotion, and consciousness:

Documentation of specific secondary conditions (i.e. Pressure Ulcers, UTI, Dysphagia, Aspiration Pneumonia) related to Alzheimer’s Disease will support eligibility for hospice care.

Details of the Karnofsky Score Performance Status

The Karnofsky Score may be requested under certain diagnoses.

Breast cancer

Progressive disease

Worsening clinical signs €“ see below
Worsening lab values
Decreasing functional status
Evidence of metastatic disease

Clinical signs

Pain, nausea or vomiting
Thrombosis or DIC
Bone marrow involvement requiring transfusion
Superior vena cava syndrome

Disease stage

Stage IV (any T, any N, M1) at presentation
Progression of any earlier stage of disease to metastatic with either of the following:

Patient continues to decline in spite of definitive therapy
Patient refuses further treatment

Performance status

Karnofsky score 50% or less
Karnofsky score 70% or higher, if patient has progressive disease, declines therapy, or does not qualify for therapy

Dementia

Must have 2 of the following

Ability to speak is limited to 6 words or fewer
Ambulatory ability is lost
Cannot sit up without assistance
Loss of ability to smile
Cannot hold up head

Patient should show all of the following characteristics

Inability to ambulate independently
Unable to dress without assistance
Unable to bathe properly
Incontinence of urine and stool
Unable to speak or communicate meaningfully

Failure to thrive/debility

Clinical signs

Progression of disease documented by symptoms or test results
Decline in Karnofsky score
Weight loss supported by decreasing albumin or cholesterol
Dependence with 2 or more of the following:

Feeding
Ambulation
Continence
Transfers
Bathing and dressing
Dysphagia leading to inadequate nutritional intake or recurrent aspiration
Increasing emergency visits, hospitalizations, or MD follow-ups related to their primary medical diagnosis
A score of 6 or 7 in the Functional Assessment Staging Test (FAST) for dementia
Progressive stage 3-4 pressure ulcers in spite of care

Heart disease

Clinical signs

Signs and symptoms of CHF at rest
Optimal dose of diuretic and vasodilator therapy
Ejection fraction of 20% or less
Cardiac symptoms:

Arrhythmias resistant to therapy
History of cardiac arrest
History of syncope
Cardiogenic brain embolism

liver disease

Cirrhosis/hepatic failure - not a candidate for liver transplant
Ascites refractory to medical management (Dietary sodium restriction and diuretics)
Hepatorenal syndrome

Oliguria
Urine Na < 10 mEq/L
Elevated BUN/creatinine

Hepatic encephalopathy refractory to medical management
Hepatocellular carcinoma
Recurrent variceal bleeding/spontaneous bacterial peritonitis

Lung cancer

Progressive disease

Worsening clinical signs €“ see below
Worsening lab values
Decreasing functional status
Evidence of metastatic disease, especially brain

Clinical signs

Pain, nausea or vomiting
Dyspnea
Significant hemoptysis
Superior vena cava syndrome
Recurrent pneumonia
Pericardial effusion/pleural effusion
Any metastasis

Disease stage

Stage IV (any T, any N, M1) at initial diagnosis
Stage III disease with pleural effusion
A patient with stage III disease who continues to decline in spite of therapy, or refuses therapy
Performance status Karnofsky score of 70% or less

Prostate cancer

Progressive disease

Worsening clinical signs €“ see below
Decreasing functional status
Evidence of metastatic disease

Clinical signs

Pain, nausea or vomiting
Thrombosis or DIC
Bone marrow involvement requiring transfusion

Disease stage

Stage IV (any T,N,or M1) at initial diagnosis
Progression of an earlier stage of disease with either of the following:

Patient continues to decline despite definitive therapy
The patient is refractory or refuses further treatment

Performance status

Karnofsky score of 50% or less
Karnofsky score of 70% or less, if patient has progressive disease on therapy, or declines therapy

Pulmonary disease

Clinical signs

Progression of disease documented by any of these symptoms:

Dyspnea at rest
Dyspnea on exertion
Homebound/chairbound
Oxygen dependent
Copius/purulent sputum
Cyanosis: fingertips, lips
Barrel chested
Poor response to bronchodilators

Functional status

Decline in Karnofsky score
Increased hospitalizations for pulmonary infections
Decrease in FEV1 on serial testing of greater than 40 ml/year
Hypoxemia at rest on supplemental oxygen
Unintentional weight loss in the past 6 months
Resting tachycardia (more than 100 per minute)

Renal disease

Clinical signs

Uremia: clinical signs of renal failure:
Confusion, obtundation
Intractable nausea and vomiting
Generalized pruritus
Restlessness
Oliguria: urine output of less than 400 cc/24 hours
Intractable hyperkalemia: persistent serum potassium more than 7.0 not responsive to medical treatment
Uremic pericarditis
Hepatorenal syndrome
Intractable fluid overload

Laboratory criteria

Both must be present:

Creatinine clearance of less than 10 cc/minute
Serum creatinine of more than 8.0 mg/dl

Stroke and coma

Clinical/functional status

A continuous decline in clinical or functional status means the patient's prognosis is poor acute phase patients
Comatose state lasting more than 3 days
Comatose patients with any 4 of the following on day 3 of a stroke have 97% mortality by 2 months:

Abnormal brain stem response
Absent verbal response
No response to pain
Serum creatinine of more 1.5 mg/dl
Age 70 or more
Dysphagia severe enough to prevent them from receiving food or fluids

All other conditions

The patient has a life-limiting condition
The patient and family have been informed that the condition is life-limiting
There is documentation of clinical progression of the disease

serial physician assessment
laboratory studies
radiologic or other studies
multiple ER visits
inpatient hospitalizations
home health nursing assessment if patient is homebound

There's a recent decline in functional status, such as:

requires considerable assistance and frequent medical care
is disabled, requires special care and assistance, is unable to care for self, disease may be progressing rapidly
Severely disabled, although death is not imminent
Very sick, active supportive treatment is necessary
Moribund, fatal processes progressing rapidly
and/or
Patient is dependent in at least 3 of these activities: bathing, dressing, feeding, transfers, continence of urine and stool, ambulation to bathroom
and/or
recent impaired nutritional status, as evidenced by unintentional, progressive weight loss of 10% over past six months, or serum albumin less than 2.5 gh/dl (may be helpful prognostic indicator but should not be used by itself)

The Palliative Performance Scale for Cancer Patients

“Accurate prognostication of the trajectory of an illness provides multiple benefits in end-of-life care. Prognostic information facilitates more realistic decision making regarding ongoing treatment, fosters risk-benefit considerations of specific interventions, and contributes to appropriate utilization of health care services. The Palliative Performance Scale (PPS) has been used as a tool for measurement of functional status in palliative care. This study explores the application of the PPS as a tool for projecting length of stay until death or discharge in a home-based hospice program.

PPS scores were associated with length of survival. Negative-change scores were predictive of patient decline toward death, while stable PPS ratings over time resulted in discharge consideration. The tool as used by this hospice was not highly discriminating between the 30% to 40% scores or the 50% to 70% scores.

CONCLUSION: The PPS scores are associated with patient length of survival in a hospice program and can be used in evaluating hospice appropriateness.

Journal of Palliative Medicine (2005) Volume: 8, Issue: 3, Pages: 492-502

“Current literature suggests clinicians are not accurate in prognostication when estimating survival times of palliative care patients. There are reported studies in which the Palliative Performance Scale (PPS) is used as a prognostic tool to predict survival of these patients. Yet, their findings are different in terms of the presence of distinct PPS survival profiles and significant covariates.

This study investigates the use of PPS as a prognostication tool for estimating survival times of patients with life-limiting illness in a palliative care unit. These findings are compared to those from earlier studies in terms of PPS survival profiles and covariates.

RESULTS: Study findings revealed that admission PPS score was a strong predictor of survival in patients already identified as palliative, along with gender and age, but diagnosis was not significantly related to survival. We also found that scores of PPS 10% through PPS 50% led to distinct survival curves, and male patients had consistently lower survival rates than females regardless of PPS score.

CONCLUSION: Our findings differ somewhat from earlier studies that suggested the presence of three distinct PPS survival profiles or bands, with diagnosis and non-cancer as significant covariates. Such differences are likely attributed to the size and characteristics of the patient populations involved and further analysis with larger patient samples may help clarify PPS use in prognosis.”

Journal of Palliative Medicine (2006) Volume: 9, Issue: 5, Pages: 1066-1075

“The Palliative Performance Scale (PPS) was first introduced in 1996 as a new tool for measurement of performance status in palliative care. PPS has been used in many countries and has been translated into other languages.

Results: The intra-class correlation coefficients for absolute agreement were 0.959 and 0.964 for Group 1, at Time-1 and Time-2; 0.951 and 0.931 for Group 2, at Time-1 and Time-2 respectively. Results showed that the participants were consistent in their scoring over the two times, with a mean Cohen's kappa of 0.67 for Group 1 and 0.71 for Group 2. In the validity study, all experts agreed that PPS is a valuable clinical assessment tool in palliative care. Many of them have already incorporated PPS as part of their practice standard.

Conclusion: The results of the reliability study demonstrated that PPS is a reliable tool. The validity study found that most experts did not feel a need to further modify PPS and, only two experts requested that some performance status measures be defined more clearly. Areas of PPS use include prognostication, disease monitoring, care planning, hospital resource allocation, clinical teaching and research. PPS is also a good communication tool between palliative care workers.”

BMC Palliative Care (2008) Volume: 7, Issue: 2, Publisher: BioMed Central, Pages: 10

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