How To Identify Patients Near End Of Life
Health care professionals can determine which patients are near the end of their lives by identifying specific medical conditions or changes in functional status. The presence of any of the following conditions should prompt the consideration of an appropriate end-of-life care plan consistent with the patient’s wishes:
- Clinical progression of the disease that includes the following:
- Frequent changes in condition requiring physician intervention
- Multiple emergency room visits or hospitalizations.
- A recent decline in functional status not secondary to reversible causes with Karnofsky Performance Status of ≤50 to determine the following:
- 50: Requires considerable assistance and medical care
- 40: Disabled; requires special care, unable to care for self, disease is progressive
- 30: Severely disabled
- 20: Very sick, active supportive treatment necessary
- 10: Moribund; fatal processes progressing.
- Malnutrition, as supported by the following:
- Unintentional weight loss ≥10% within six months; or
- Serum albumin <2.4 g/dl.
- Presence of any of the following medical complications:
- Aspiration pneumonia;
- Recurrent urosepsis;
- Decubitus ulcers (multiple, stage III or IV);
- Inability to maintain caloric needs (and declining a feeding tube); and
- Recurrent falls.
- Presence of dementia, such as end-stage Alzheimer’s or multi-infarction.
- Congestive heart failure, with New York Heart Association Class IV signs and symptoms, including severe limitations and symptoms even while at rest.
- Pulmonary disease, including the following: chronic obstructive pulmonary disease or pulmonary fibrosis with dyspnea at rest, poor response to therapy, and reduced functional activity.
- Stroke: Large hemispheric or brain stem infarction.
- End-stage renal disease, with a serum creatinine of >5 mg/dl.
- Liver disease with coagulopathy (PT >5 seconds over control) and malnutrition (serum albumin <2.4 mg/dl).
- The presence of neoplasm or advanced human immunodeficiency virus (HIV).
Of the above conditions, unintentional weight loss, pressure ulcers, and recurrent falls are often overlooked by health care professionals as hallmarks of the dying process.
Source: Maximo Diamond, MD