Guiding Principles for the Care of Older Adults with Multimorbidity
Guiding Principle: III. Prognosis Domain
Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (e.g., remaining life expectancy, functional status, quality of life) for older adults with multimorbidity.
How to Use in Clinical Practice
| Goal |
Tools, Resources, Strategies |
| Incorporate prognosis into clinical decision-making. |
- Frame a focused clinical question;
- Determine the outcome being predicted (e.g., remaining life expectancy, functional ability, quality of life, or a condition-specific risk such as stroke);
- Select a prognosis measure, while recognizing its strengths and weaknesses;
- Estimate prognosis;
- Integrate this information into the decision-making process.
|
| Prioritize decisions based on life expectancy or other relevant outcomes. |
Minimize treatments or interventions unlikely to provide benefit and limit harms without benefit by making decisions based on prognosis categories:
- short-term (death expected within the next year/highest priority) - address issues such as advance directives, need for aggressive glucose control, physical therapy;
- mid-term (death expected within the next 5 years)
- long-term (death expected beyond five years).
|
| Offer to discuss prognosis. |
Many older adults wish to discuss prognosis but some do not.
Offer clinical information within the context of specific ethnic and cultural considerations for older patients, addressing principles of:
- patient autonomy (e.g., self-determination);
- beneficence (e.g., promotion of patient well-being);
- non-maleficence;
- justice.
|
| Identify situations in which a determination of prognosis may help inform clinical decision-making. |
- When making decisions about treatment or prevention (e.g., whether to start/stop a medication or insert/replace a device);
- Disease screening (e.g., for cognitive decline, cancer, osteoporosis);
- Change in clinical status of patient (e.g., weight loss, functional decline, after a fall);
- Change of health service utilization (e.g., decisions about hospitalization or initiation of aggressive ICU care).
|
| Choose an appropriate prognostic measure, based on its relevance to the individual patient. |
Examples of measures for specific diseases (1)
- The Seattle Heart Failure Model (2)
- The BODE Index (3)
- ADEPT (4)
- STOPP/START (Screening Tool to Alert to Right Treatment and Screening Tool of Older Persons' potentially inappropriate Prescriptions) (5)
- Cancer screening (6)
Life tables:
- Prognostic index based on 6 risk factors for the year following acute hospitalization (7)
- Planning for final years of life (8)
Measures based on functional status:
- Role of gait speed in survival (9)
- Chronic disability as the strongest negative risk factor for survival (10)
Integrated measures:
- 4-year prognostic index (11)
- 5- and 9-year survival indices (12)
- Vulnerable Elders-13 Survey (VES-13) (13)
Measures based on advanced illness:
- Palliative Prognostic Score (PaP) (14)
- Palliative Performance Scale (PPS) (15, 16)
|
| Decide what prognostic information to share with patient and family. |
Base choice of measure on:
- patient-stated preferences
- overall evaluation of evidence.
|
References
1. Glare PA, Sinclair CT. Palliative medicine review: Prognostication. J Palliat Med. 2008;11(1):84-103 Accessed 7 September 2011.
2. Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB, Anand I, Maggioni A, Burton P, Sullivan MD, Pitt B, Poole-Wilson PA, Mann DL, Packer M. The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation. 2006 Mar 21;113(11):1424-33. Epub 2006 Mar 13.
3. Ong KC, Earnest A, Lu SJ. A multidimensional grading system (BODE index) as predictor of hospitalization for COPD. Chest. 2005;128(6):3810-3816.
