Assessing Prognosis

Key points

  • Information about prognosis may affect patients’ and families’ decisions
    • Patients’ attitudes to treatment and interventions may shift as prognosis shortens
    • Personal priorities and preferred place of care may change  
    • Prognosis may affect the sustainability of care arrangements in the community.
  • Performance state has prognostic significance, especially in advanced cancer
    • The performance state generally reflects the burden of disease. Rate of change is a global index of disease activity, and correlate to increasing constitutional symptoms (such as, anorexia, cachexia, fatigue)
    • An Australian-modified Karnofsky Performance Scale (AKPS) score of less than 40 or an Eastern Cooperative Oncology Group (ECOG) performance status score of 3 correlates to a median survival of around 3 months for patients with advanced cancer
    • A prognosis in terms of 'days', 'weeks' or 'months' can be reasonably predicted for many patients with cancer.
  • Specific prognostic guidance (SPICT) is available for a range of advanced non-malignant conditions. 
  • Palliative care services cannot provide long-term in-patient care, so 
    • Families may sometimes need to consider residential aged care if the prognosis is months, and the need for good physical nursing is the main focus of the person’s care.
  •  It is important to identify the onset of the terminal phase in order to ensure appropriate care is provided.

AKPS - Assesses performance status

The AKPS is a measure of the patient’s overall performance status or ability to perform their activities of daily living. It is a single score between 10 and 100 assigned by a clinician based on observations of a patient’s ability to perform common tasks relating to activity, work and self-care. A score of 100 signifies normal physical abilities with no evidence of disease. Decreasing numbers indicate a reduced performance status.
 
AKPS ASSESSMENT CRITERIA SCORE
Normal; no complaints; no evidence of disease 100
Able to carry on normal activity; minor sign of symptoms of disease 90
Normal activity with effort; some signs or symptoms of disease 80
Cares for self; unable to carry on normal activity or to do active work 70
Able to care for most needs; but requires occasional assistance 60
Considerable assistance and frequent medical care required 50
In bed more than 50% of the time 40
Almost completely bedfast 30
Totally bedfast and requiring extensive nursing care by professionals and/or family 20
Comatose or barely rousable 10
Dead 0

Serial AKPS scores are a valuable way to monitor disease activity and treatment.
 

From: Palliative Care Outcomes Collaborative (PCOC) (Go to Assessment tools and AKPS)
Ref: Abernethy AP, Shelby-James T, Fazekas BS, Woods D, Currow DC. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice. BMC Palliat Care. 2005 Nov 12;4:7.


ECOG - Assesses performance status

ECOG PERFORMANCE STATUS*
Grade ECOG
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead

The ECOG Performance Status is in the public domain therefore available for public use. To duplicate the scale, please cite the reference above and credit the Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair.
 

From: Eastern Cooperative Oncology Group (ECOG)
* As published in Am. J. Clin. Oncol.
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982 Dec;5(6):649-55.


SPICT - Prognostic guidance for cancer, organ failure and dementia

Supportive and Palliative Care Indicators Tool (SPICT)
  • General prognostic indicators are provided for all patients approaching end-of-life
     
  • Specific prognostic indicators are provided for a range of common medical conditions: cancer, chronic obstructive pulmonary disease, heart disease, renal disease, general neurological disease, motor neurone disease, Parkinson’s disease, multiple sclerosis, stroke, dementia and frailty.

Ref: Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study. BMJ Support Palliat Care. 2014 Sep;4(3):285-90. Epub 2013 Jul 25.


Palliative Care Network of Wisconsin Fast Facts - Additional resources related to prognostication

# 013 Determining Prognosis in Advanced Cancer, 2nd ed
How long do I have, Doc?

# 030 Prognostication, 2nd ed
Physicians tend to be overly optimistic when dealing with prognosis.

# 099 Chemotherapy: Response and Survival Data, 2nd ed
The table synthesises data for several common cancers.

# 124 The Palliative Prognostic Score
This Fast Fact reviews the Palliative Prognostic Score (PaP).

# 125 The Palliative Performance Scale (PPS)
This Fast Fact reviews the Palliative Performance Scale.

# 141 Prognosis in End-Stage COPD
This Fast Fact reviews prognostication in patients with advanced COPD.

# 143 Prognostication in Heart Failure
This Fast Fact reviews prognostication in Heart Failure (HF).

# 150 Prognostication in Dementia
This Fast Fact reviews prognostication in dementia.

# 179 CPR Survival in the Hospital Setting
This Fast Fact reviews data on CPR outcomes in hospitalised patients.

# 189 Prognosis in Decompensated Chronic Liver Failure
This Fast Fact reviews prognosis in chronic liver failure, focusing on two validated prognostic indices.

# 191 Prognostication in Patients Receiving Dialysis
This Fast Fact reviews the current data regarding prognostication in patients receiving chronic hemo- and peritoneal dialysis.

# 213 Prognosis in HIV and AIDS
This Fast Fact reviews prognostication in patients who are suffering life-threatening complications related to HIV infection using data where combination antiretroviral therapy (cART) was available.

# 214 Prognosis in HIV Associated Malignancies
This Fast Fact presents survival data for malignancies commonly arising in the setting of HIV / AIDS.

# 234 Prognosis of Anoxic-Ischemic Encephalopathy
This Fast Fact reviews the progosis of patients who intially survive cardiopulmonary resuscitation but remain comatose, demonstrating obvious impairments in neurologic function.
 

From: Palliative Care Network of Wisconsin, US

Last updated 14 February 2017