Guideline for Estimating Length of Survival

in Palliative Patients
Cornelius Woelk MD, CCFP
Medical Director of Palliative Care
Regional Health Authority - Central Manitoba
385 Main Street Winkler, Manitoba, Canada R6W 1J2
Ph: 204-325-4312 Fax: 204-325-4594
Email: cwoelk@web4.net
Mike Harlos MD, CCFP, FCFP
Professor, Faculty of Medicine, University of Manitoba
Medical Director, Palliative Care Sub Program, Winnipeg Regional Health Authority
Medical Director, St. Boniface General Hospital Palliative Care
Room A8024, St. Boniface General Hospital, 409 Tach Ave.,
Winnipeg, Manitoba, Canada R2H 2A6
Phone: 1-204-235-3929 Fax: 1-204-237-9162 Pager: 1-204-932-6231
Physicians are frequently asked questions around expected time of survival, mostly by patients
and families. Additionally, with increasing availability and awareness of palliative care services,
there will be a need to define eligibility criteria, which will be in part based on prognosis.
Physicians by and large know that their estimates are just that: estimates. Patients and families
generally understand that as well. However, prognosticating carries with it some risks.
Overestimating the length of survival (the more common error, according to studies) leaves
families feeling they have been robbed of time. Underestimating leaves the patient and family
wondering when the end is about to appear, and perhaps questioning the credibility of the source
of that information. All involved need to realize that estimates are not guarantees, and that
conditions at this time of life may change rapidly.
A number of studies have attempted to address the issue of estimating length of survival in
individuals with terminal disease
1
. Although there are no mechanisms to predict the future with
certainty, the following may help in determining the matter for the patient at hand.
A. Diagnosis with a poor prognosis
Some illnesses are associated with a diagnosis that virtually always carries a poor prognosis.
Examples would include pancreatic cancer, most biliary tract cancers, metastatic
adenocarcinomas of unknown primary, and untreated small cell lung cancers.
B. Circumstances with a very poor prognosis
In addition to the functional decline is usually seen in the terminal phase of progressive illness,
there are some circumstances that have a very poor prognosis in specific illnesses:

Cancer: multiple metastases to the brain, liver, or lung
refractory hypercalcemia
ongoing bleeding from tumour, or bone marrow failure without
transfusions
CHF: hemodynamic failure requiring inotropic support
progressive renal insufficiency
repeated hospital admissions
Renal Failure: discontinuation of dialysis
severe hyperkalemia without treatment
COPD: respiratory failure
Misc: sepsis in a frail, bedridden patient
any condition causing coma where fluids are not given (e.g. massive
CVA, post-resuscitative hypoxic encephalopathy)
Email: mike@harlos.net


C. Illnesses showing a momentum of functional decline
The momentum of decline in functional status, when interpreted in the context of other
parameters of physiologic decline (such as organ failure), provides some of the most intuitively
valid information for prognosticating terminal illness. The underlying premise is that there tends
to be a consistency to the rate of functional decline as the end of life nears; rapid changes tend to
continue rapidly, and slow changes continue slowly (although the final changes often occur
quickly).
An illness whose functional decline is noted month-to-month will likely continue for a number of
months. An illness whose functional decline is noted weekly is likely to continue for a number of
weeks. Daily functional decline may indicate a prognosis limited to days.
By observing the course of the illness thus far, and understanding the illness, one can make
general estimates of future deterioration. It would of course be important to distinguish between
reversible and irreversible causes resulting in the functional decline.
Clinical prediction of survival has been found to be erroneous (defined as more than double or
less than half of actual survival) 30 % of the time in expert hands. Two thirds of errors are based
on over-optimism and one third on over pessimism. Pain has not been associated with length of
survival (except unendurable pain in one study). Treatment with opioid analgesics has not
been found to impact length of survival.

The following is a summary of a few studies that address estimating survival in patients with a
terminal disease. Initially, study of the Karnofsky Performance Status (Table 1) showed that
performance status is an important predictor of survival. Further work has attempted to refine the
ability to predict length of survival. Preexisting disease, prior treatment, psychological status and
social support may affect the length of survival in a terminal illness.

Table 1. Karnofsky Performance Scale

% Criteria
100 Normal; no complaints; no evidence of disease
90 Able to carry out normal activity; minor signs or symptoms of disease
80 Normal activity with effort; some signs or symptoms of disease
70 Cares for self; unable to carry on normal activity or do active work
60 Requires occasional assistance, but is able to care for most of his/her needs
50 Requires considerable assistance and frequent medical care
40 Disabled; requires special care and assistance
30 Severely disabled; hospitalization is indicated although death not imminent
20 Very sick; hospitalization necessary, active supportive treatment necessary
10 Moribund; fatal processes progressing rapidly
0 Dead

The Palliative Performance Scale (PPS) is a modification of the Karnofsky Performance Scale
(KPS), designed specifically for measurement of physical status in Palliative Care (Table 2).
2

Using the Palliative Performance Scale, only about 10% of patients with a score of 50% or less
would be expected to survive more than 6 months.
3



Certain clinical factors increase the predictive value of estimated length of survival when used
along with performance status. In one small prospective study, for example, it was demonstrated
that there was a significant relationship between length of survival and dysphagia, cognitive
failure and weight loss.
4
The presence of all three factors weight loss of 10 kg or more, MMSE
of < 24, and dysphagia to solids or liquids predicted survival of less than 4 weeks with an
accuracy of 74 %. The estimates in this study were equivalent to that of two physician estimates.

Table 2. Palliative Performance Scale
% Ambulation Activity and
Evidence of
Disease
Self-Care Intake Level of
Consciousness
Normal Activity
100 Full
No Evidence of
Disease
Full Normal Full
Normal Activity
90 Full Some Evidence of
Disease
Full Normal Full
Normal Activity
with Effort
80 Full
Some Evidence of
Disease
Full
Normal or
Reduced
Full
Unable to do
Normal Job / Work
70 Reduced
Some Evidence of
Disease
Full
Normal or
Reduced
Full
Unable to do
Hobby / House
Work
60 Reduced
Significant Disease
Occasional
Assistance
Necessary
Normal or
Reduced
Full or
Confusion
Unable to Do Any
Work
50 Mainly Sit/Lie
Extensive Disease
Considerable
Assistance
Required
Normal or
Reduced
Full or
Confusion
40 Mainly in Bed As Above
Mainly
Assistance
Normal or
Reduced
Full or Drowsy
or Confusion
30
Totally Bed
Bound
As Above Total Care Reduced
Full or Drowsy
or Confusion
20 As Above As Above Total Care Minimal Sips
Full or Drowsy
or Confusion
10 As Above As Above Total Care
Mouth Care
Only
Drowsy or
Coma
0 Death -- -- -- --



Other studies have used clinical symptoms along with performance scales. The Palliative
Prognostic Index (PPI) is an example of such a tool (Table 3), using the PPS along with oral
intake, edema, dyspnea at rest and delirium.
5
If the PPI is greater than 6.0, survival is less than
three weeks (Sensitivity 80 %; Specificity 85 %).


Table 3. Palliative Prognostic Index (PPI)
Max. Possible
10 20 4.0
30 50 2.5
Palliative
Performance
Scale
> 60 0
4.0
Severely Reduced ( mouthfuls) 2.5
Moderately Reduced (> mouthfuls) 1.0 Oral Intake
Normal 0
2.5
Present 1.0
Edema
Absent 0
1.0
Present 3.5
Dyspnea at rest
Absent 0
3.5
Present 4.0
Delirium
Absent 0
4.0
Total 15


One prognostic score, the PaP (for Palliative Prognostic Score [Table 4]), includes use of
anorexia, dyspnea, total white blood count, and lymphocyte percentage along with the KPS and
expert clinical prediction of survival.
6
Based on the results of these variables, patients are
considered to belong to one of three prognostic groups, reflecting 30-day survival probability of
>70%, 30-70%, or <30%.

As in much of palliative care, studies addressing prognosis mostly deal with advanced cancer.
The advanced cancer trajectory may be significantly different from that of other advanced
illnesses. Diseases resulting in chronic organ failure, such as chronic obstructive pulmonary
disease, congestive heart failure, and end-stage liver disease, tend to run a more fluctuating
course and result in death in a less predictable time.
7

It is clear that performance status is related to length of survival. In the cancer population,
clinical symptoms of anorexia, weight loss, dysphagia, and cognitive failure have been shown to
have predictive value for survival. In any case, it remains that when predicting length of survival
it is most useful to have observed the patient over a period of time, to understand the illness, and
to have a sense of psychological and social issues involved. It is of course important to have
ongoing good communication with the individual and his or her family. Observation over a
period of time will provide a sense of the momentum of functional decline. This momentum may
provide the most accurate estimate of length of survival


Table 4. PaP Score and Classification of Patients in
Three Risk Groups
Dyspnea
No 0
Yes 1
Anorexia
No 0
Yes 1.5
Karnofsky Performance Status
30 0
20 2.5
Clinical Prediction of Survival (weeks)
>12 0
11 - 12 2.0
9 10 2.5
7 8 2.5
5 6 4.5
3 - 4 6.0
1 - 2 8.5
Total WBC
Normal (4.8-8.5) 0
High (8.5-11) 0.5
Very high (>11) 1.5
Lymphocyte %
Normal (20-40) 0
Low (12-19.9) 1.0
Very Low (< 11.9) 2.5
Total 0 - 17.5
Risk Groups According to Total Score:
30-day survival probability Total Score
> 70% 0 5.5
30 70% 5.6 11.0
< 30 % 11.1 17.5


REFERENCES

1
Chow E, et al. How Accurate are Physicians Clinical Predictions of Survival and the Available Prognostic Tools
in Estimating Survival Times in Terminally Ill Cancer Patients? A Systematic Review. Clinical Oncology 2001; 13:
209-18.

2
Anderson F, Downing GM, Hill J, Casorso L, Lerch N. Palliative Performance Scale (PPS): A New Tool. J Palliat
Care 1996; 12(1): 5-11.

3
Morita T, Tsunoda J, Inoue S, Chihara S. Validity of the Palliative Performance Scale from a Survival Perspective.
J Pain and Symptom Manage 1999;18:2-3.



4
Bruera E, Miller MJ, Kuehn N, MacEachern T, Hanson J. Estimate of Survival of Patients Admitted to a Palliative
Care Unit: A Prospective Study. J Pain Symptom Manage 1992; 7(2): 82-86.

5
Morita T, Tsunoda J, Inoue S, Chihara S. The palliative prognostic index: a scoring system for survival prediction
of terminally ill cancer patients. Supportive Care in Cancer 1999; 7: 128-33.

6
Maltoni M, et al. Successful Validation of the Palliative Prognostic Score in Terminally Ill Cancer Patients. J Pain
and Symptom Manage 1999;17:240-247.

7
Fox E, et al. Evaluation of Prognostic Criteria for Determining Hospice Eligibility in Patients With Advanced
Lung, Heart, or Liver Disease. JAMA 1999; 282:1638-45.