Sivakumar Subramaniam

Accuracy of prognosis prediction by PPI in hospice inpatients with cancer: a multi-centre prospective study

The Palliative Prognostic Index (PPI) is a prognostication tool for palliative care patients based on clinical indices developed in Japan and further validated by one study in the UK. The aim of this study was to test its prediction accuracy in a large inpatient hospice sample. The admitting doctor in three inpatient hospices calculated the PPI score on admission. Two hundred and sixty-two patients were included in this study. Based on the PPI score, three subgroups were identified. Group 1 corresponded to patients with PPI ≤4 and the median survival of 53 days (95% CI 40 to 80 days). Group 2 corresponded to those with PPI >4 and ≤6 and the median survival 15 days (95% CI 12 to 26 days) and Group 3 corresponded to patients with PPI >6 and the median survival of 5 days (95% CI 3 to 7 days). In this study, PPI was able to identify patients’ likelihood of dying within 3 weeks with a sensitivity of 64% and specificity of 83%. It was able to identify a 6-week survival chance with a sensitivity of 62% and specificity of 86%. A one-unit increase in PPI score was estimated to increase the hazard for death by a factor of 1.33 (95% CI 1.26 to 1.40), based on fitting a stratified Cox proportional hazards model. The authors conclude that PPI can be used to predict prognosis for patients with advanced cancer.

Prognosis prediction with two calculations of Palliative Prognostic Index: further prospective validation in hospice cancer patients with multicentre study

Objectives In palliative care settings, predicting prognosis is important for patients and clinicians. The Palliative Prognostic Index (PPI), a prognostic tool calculated using clinical indices alone has been validated within cancer population. This study was to further test the discriminatory ability of the PPI (ie, its ability to determine whether a subject will live more or less than a certain amount of time) in a larger sample but with a palliative care context and to compare predictions at two different points in time. Methods Multicentre, prospective, observational study in 10 inpatient hospices in the UK. The PPI score was calculated on the day of admission (PPI1) and again once on days 3–5 of inpatient stay (PPI2). Patients were followed up for 6 weeks or until death, whichever was earlier. Results Of the 1164 patients included in the study, 962 had both scores available. The results from PPI2 showed improved sensitivity, specificity, positive predictive value and negative predictive value compared with PPI1. For PPI1versus PPI2, area under receiver operator character curve (ROC) for <21 days were 0.73 versus 0.82 and for ≥42 days prediction 0.72 versus 0.80. The median survival days for patients with PPI1 ≤4, 4.5–6 and >6 were 38 (31 to 44), 17 (14 to 19) and 5 (4 to 7). Conclusion This study showed improved discriminatory ability using the PPI score calculated between day 3and day5 of admission compared with that calculated on admission. This study further validated PPI as a prognostic tool within a palliative care population and showed recording at two time points improved accuracy.

P-108 Audit of documentation of end of life care priorities in patients under local hospice services

Background Although majority of patients in UK want to die at home, about 50% die in Hospital. Many Hospices and clinical commissioners consider achievement of preferred place of death as a quality marker for the palliative care service. Studies show formal recording of preferred place of death, improves the chance of achieving it. Aim This audit was planned to check the documentation levels of aspects of preferred place of care, preferred place of death, Resuscitation. We also included the documentation of carer’s preferences as well. Methods At our Hospices, electronic case note system (infoflex) is used to record preferred place of care (PPoC), Resuscitation status (DNAR) and preferred place of death (PPoD). We checked the above aspects on 15 inpatients (IPU) and 15 Home care team patients (HCT) and 15 day therapy patients (DTU). Those patients seen at least 3 times by the professionals only included as some occasions might not be appropriate to discuss these on the first review. Results The majority of patients from DTU and HCT had their first preference for place of care recorded on the system (14/15 of HCT, 12/15 DTU). Only 10/15 IPU patients had this recorded. Hardly any patients had their second choice of place of care recorded on the system. (2/45). The majority of HCT and DTU patients had their first choice place of death recorded on Infoflex (13/15 and 11/15), however only 60% of IPU patients did (9/15) making 33/45 in total. Only around 7 out of 45 patients had their second preference place of death recorded. Preferred place of death was achieved by 60% of IPU patients, 80% of HCT patients and 70% of DTU patients who had died according to the information. DNAR status was completed in 42/45. ACP discussion was not recorded in the majority of patients seen by IPU and HCT. Conclusion The audit showed areas of good practice and also some need for improving of recording of these important indices. This was presented to the teams and further audits planned.

An audit on ‘death rattle’ (noisy breathing at the end of life), and usage of antisecretory medicat

‘Noisy breathing’ also known as death rattle, is common in end of life care situations and can be distressing for the family given its unpleasant resonance. A recent Cochrane review by Wee et al (2009 review) concluded that there is no evidence to show any intervention was superior to placebo; it is very difficult to subsequently manage. Aim To evaluate current practice against national guidelines on the use of antisecretory medications in end of life care. Methodology Retrospective, case notes review of all the patients died in the authors unit (Jan 2011–May 2011). Results Seventy-two patients were identified with 65 patients having antisecretory drugs prescribed and 36 patients requiring medications. 49/65 had complied with the recommended guidance with only 29/36 having a documentation of a response. 7/36 patients with no documentation of assessment. 24/29 patients had documented benefit from the antisecretory drug and a syringe driver started in 24/36 cases. Apart from drugs evidence of other modalities used was lacking: 3/36 patients evidence of re-positioning only. Documentation of communication with family was only in 4/36. 22/36 patients died within 48 h from 1st dose of antisecretory given and 16/24 patients died within 24 h of the syringe driver starting. Conclusion In a majority of patients medications used appropriately and response assessment completed. However, documentation of communication with family and other approaches needs to be improved. Interestingly when antisecretory drugs were used death ensued within 48 hrs for the majority. Education of all staff members is extremely important along with regular audit.

Comparing the use of Edmonton symptom assessment system (ESAS-r) in hospice & oncology outpatients

Current guidance, nationally and internationally, would suggest within oncology and hospice outpatient settings holistic assessment be completed. However how this should occur and what assessment tool be used, there is no agreed consensus. Aim To explore the use of a validated patient reported symptom assessment tool within a lung oncology and hospice outpatient setting. Methodology An exploratory study looking at patient reported ESAS-r assessment form completion prior to attending their clinic review with an oncology and hospice setting and the data collected, analysed for comparison. Results Total number of Hospice patents: 22 (male13: female 9), age: 42–80 versus total number of Oncology out patients: 26 (male14: female 12), age: 54–91. The median total symptom score for hospice outpatients was 34.5/100 versus median total score for Oncology outpatients was 23.5/100. Tiredness (6.5/10) and drowsiness (5/10) were the high scoring symptoms within hospice outpatients while tiredness (5/10) and wellbeing (5/10) were in the lung cancer outpatient setting. The median score for pain and shortness of breath was 3/10 & 0/10 in Hospice patients versus 1/10 & 1.75/10 in Oncology clinic patients. Conclusion The symptom scores were comparable and not surprisingly the median scores were higher in the hospice outpatient setting. The physical and psychological symptoms scored significantly higher in the hospice outpatient population. The authors acknowledge the small sample size and this was an exploratory piece of work. However, clinicians found the ESAS-r tool to be clinically useful and helped focus discussions about what was important from a patients agenda but helped in the disclosure of commonly ignored symptoms such as fatigue. This then prompted further assessment for eligibility for clinical trials specifically directed at fatigue management. Therefore the use of a patient, self-reported holistic assessment tool is a useful addition to oncology and hospice outpatient clinics.