Aging, e-prognosis, ethical perspective, geriatricians, health care, Hospice, Jewish medical Ethics, medical ethics, paula span
A new website was launched a short while ago called e-prognosis. Its stated goal is to estimate a prognosis for the elderly in terms of length of life. Two pieces by Paula Span, here and here, discuss the website. While I am not sure I would want a statistical probability indicating my life expectancy like this website, which I am not eligible to use for many years, it is interesting nevertheless. From an ethical perspective, I think a prognosis tool is problematic as doctors could now turn to the probability and say, since your chances of living more than … is only 25% as per your current conditions, etc., we strongly suggest no more treatments. For many, hearing this number might cause people to make decisions they are not emotionally or culturally/religiously comfortable with. I realize that the medical world today is looking for means of saving on unnecessary testing, etc. but we, who are not omniscient, cannot know with 100% certainty whether probability is enough of a reason to recommend treatment or non-treatment in a particular situation. The human error element will remain and the medical field needs to be tuned into the human element of decision-making. It will be interesting to see how this prognosis system plays out.
How Long Until the End?By PAULA SPAN
Last spring, I wrote about a group of geriatricians and researchers assembling online a variety of geriatric indexes that do a reasonably good job of predicting mortality for those over age 60. Since a number of tests and treatments ought to take life expectancy into account, they reasoned, physicians should have these validated tools in one handy online location.
Their question was whether the Web site they were putting together should be accessible to the public as well. Would non-professionals be apt to misinterpret the numbers? Or to decide that if they had plenty of life expectancy remaining, they might as well smoke? While the researchers were debating, I put this question to New Old Age readers: Do you want to be able to use the site, too?
The near-unanimity of your responses was startling. Roughly 75 people commented, and roughly 72 of you said (I’m paraphrasing), “Hell, yes.”
As promised, therefore, I’m alerting you to the launch of ePrognosis. The Web site includes 16 interactive assessment tools — some for older adults in hospitals and nursing homes, some for those still living in the community, some that predict the odds of living for six months or a year, some for four or five years. The site asks if you are a health care professional; there is no verification. The researchers anticipate that some members of public will venture onto the Web site to learn a bit on their own.
All kinds of health care decisions are influenced, or should be, by how much longer you’re likely to survive. Should you or your elderly relative keep taking a statin? Agree to a mammogram? Enroll in hospice care?
Plugging in my own variables, I see that I am doomed to further colonoscopies, alas. But my father, at 89, is a different story.
The ePrognosis creators have explained all this in a study published today in the Journal of the American Medical Association. You can also read my news story about it.
If you venture to the site, I hope you’ll come back and tell us what you think. Was it simple to use? Will it help you make decisions?
Do you wish you didn’t know?
Using Interactive Tools to Assess the Likelihood of Death
New online tools to help determine life expectancy may influence how doctors treat and prescribe drugs for the elderly.
By PAULA SPAN
Published: January 10, 2012
To help prevent overtesting and overtreatment of older patients — or undertreatment for those who remain robust at advanced ages — medical guidelines increasingly call for doctors to consider life expectancy as a factor in their decision-making. But clinicians, research has shown, are notoriously poor at predicting how many years their patients have left.
Now, researchers at the University of California, San Francisco, have identified 16 assessment scales with “moderate” to “very good” abilities to determine the likelihood of death within six months to five years in various older populations. Moreover, the authors have fashioned interactive tools of the most accurate and useful assessments.
On Tuesday, the researchers published a review of these assessments in The Journal of the American Medical Association and posted the interactive versions at a new Web site called ePrognosis.org, the first time such tools have been assembled for physicians in a single online location.
“We think a more frank discussion of prognosis in the elderly is sorely needed,” said Dr. Sei Lee, a geriatrician at U.C.S.F. who co-authored the review. “Without it, decisions are made that are more likely to hurt patients than help them.”
Dr. Lee and his colleagues cautioned that while the best assessments are reasonably accurate, there is insufficient data on whether using use of them improves patient care in clinical settings. The researchers stopped short of urging widespread implementation.
At present, physicians are often shooting in the dark when they recommend tests, treatments and medications for older patients. Older bodies respond differently than younger ones to drugs and operations, many of which are never evaluated in elderly populations.
Even when interventions do work, the benefits can be years away. Doctors have no easy way to know whether their elderly patients will live long enough to experience them. The potential for complications and side effects, however, is immediate.
Plugging individual variables — age, health conditions, cognitive status, functional ability — into one of the new online tools produces a percentage indicating the likelihood of death within a particular time frame. Some assessments are used for hospital patients or nursing home residents, others for seniors still living in the community.
“That kind of synthesis is very helpful for providers, researchers, some patients — a one-stop shop,” said Dr. Susan L. Mitchell, a geriatrician and senior scientist at Hebrew Senior Life in Boston, who was not involved in the project.
The results could help doctors and families evaluate, for example, whether an older person with a terminal disease should consider hospice care, Dr. Lee said.
Medicare regulations require that hospice patients have a prognosis of six months or less, but most patients don’t turn to hospice until they are within a few weeks or days of death, when there’s little time to provide full medical and psychological support.
At ePrognosis.org, physicians can consult the Porock Scale, used for assessing life expectancy in long-term nursing home residents. The scale indicates, for example, that a man in his late 80s with congestive heart failure, failing kidneys, weight and appetite loss, declining cognitive ability and the need for extensive assistance has a 69 percent chance of dying within six months.
Doctors and family members could reasonably conclude that such a person is a candidate for hospice without fearing that they’ve jumped the gun.
The assessments might also be helpful in determining how vigilant an older person with Type 2 diabetes must be about maintaining very low blood sugar, said Lindsey Yourman, now an intern at Scripps Murphy Hospital in San Diego and lead author of the review.
Keeping blood sugar below 7 percent on the commonly used A1C hemoglobin test can lower diabetics’ risk of complications like kidney disease. But it can take eight years or longer of daily monitoring, dietary restrictions, exercise and medications for that protective effect to appear.
“Say an older patient is tired of having to be so meticulous and attentive to blood sugar all the time,” Dr. Yourman said. “If she’s unlikely to live for five years, it’s questionable whether she will really benefit from tight glycemic control.”
With an accurate idea of how long the patient might live, her physician might decide her quality of life will improve with less stringent measures to manage diabetes, Dr. Yourman said.
Despite the new tools’ shortcomings, Dr. Yourman added, “they don’t have to be perfect to be better than what’s already happening.”
The authors debated whether to give the public access to ePrognosis, fearing that nonprofessionals might misinterpret the information or fail to consider how their own situations vary from a those of various study populations.
The tools are available to anyone who checks a box saying he or she is a health care professional; there here is no verification.
“As with any scientific data,” cautioned Dr. Mitchell of Hebrew Senior Life, “it needs some explanation of the accuracy of these prognostic tools. Some are better than others, and none are perfect. The public needs to understand that.”
In the end, the authors decided that creating barriers to public use would make ePrognosis less useful for physicians as well. They also wanted to bring the public into the discussion.
“This is a philosophical question,” said Dr. Lee, who described a trend toward better-informed patients participating in health care decisions. “In general, patients having more information is a good thing.”