Death watch for hospitalized seniors

Call it morbid curiosity with a purpose. A new clinical tool tells which patients have less than a year to live. Doctors and their patients may never be the same.
An aging population means more and more families are faced with challenging end-of-life decisions. But how can you tell when that end is actually going to come? Surprisingly, many doctors find it difficult to recognize which patients are close to death. A study just published in the Canadian Medical Association Journal helps take away some of the guesswork. 

"Give it to me straight, doc," goes the set up to the age old question from the patient who is given a serious diagnosis.  "How long have I got?" 

As many studies have shown, doctors are notoriously inaccurate at predicting which patients are likely to die.  They may have a feeling, but a tendency to fly by the seat of their pants reduces the doctor's prognostic abilities.  But if the doctor uses a valid decision tool, the accuracy of the doctor's prescription goes up a lot.  

A team of researchers from Canada, the US and Switzerland developed a decision tool called the Hospital-patient One-year Mortality Risk or HOMR.  The researchers used the HOMR score to look at the records of nearly three million patients admitted to hospital in Ontario between 2003 and 2010, more than 200,000 patients admitted to hospital in Alberta from 2010 to 2012, as well as close to 67,000 patients admitted to hospital in Boston between 2010 and 2012.

With slight variations depending on the location of the patient population, the overall risk of dying within one year of the admission to hospital was roughly eight point seven per cent.  The median HOMR score among Ontario patients was around 23. Some patients had lower scores and some had higher. The higher the HOMR score, the greater your risk of dying within one year.  Overall, each one-point increase in the HOMR score increased the risk of dying within one year. This was true whether you were hospitalised in Ontario, Alberta or Boston. 

What factors put patients at increased risk of dying? The HOMR score is made up of many factors. They include the age of the patient, sex, number and severity of illnesses (things like dementia, heart failure and kidney disease). For example, score an extra four points if you have moderate to severe liver disease.  If you have metastatic cancer, you get an extra six points.  Your score is higher if you need home care or if you live in a nursing home. If you arrive in hospital by ambulance, your score is higher too. The HOMR score also takes into consideration the number and type of admissions to hospital.

If your doctor calculates that your or a loved one has a high HOMR score and therefore likely to die within a year, the implications are staggering.  As a physician, if I know my patient is highly likely to die within a year, what's the point of ordering a mammogram, testing for PSA and other markers for cancer?   I'd probably let the blood pressure and blood sugar run a little higher than I would in someone unlikely to die soon. I'd certainly take the patient off cholesterol lowering drugs, since lowering cholesterol would be a complete waste of effort.

Where things might get challenging is what to do if the patient likely to die within a year falls and breaks their hip.  Do you fix it or leave it to heal naturally, knowing that either option could hasten death?

In the ideal world, patients and families should receive the information about the doctor's prognosis in order to make decisions about their health accordingly. Handled sensitively, I think it would get patients and families to think less about extending life and more clearly about how they want their lives to end.  I think they would be less likely to say yes to surgery, go on new medications or agree to an admission to hospital. That and better management of symptoms like pain might give them fewer months to live but a better quality of life.

But this isn't happening in the real world yet, and I think that's a missed opportunity. The researchers didn't say that patients and their families should be in the loop.  I think they should. I say it's time for doctors to tell patients and families that there are limits to what modern medicine can do to prolong life.

Prognostic tools like the HOMR score don't seal the fate of patients.  What they do is send a signal that it's time to move from cure to comfort.  If you're a patient and you know that, it doesn't have to be curse.  Many see it as a gift - a reminder to use the time they have more wisely and with a little tenderness.


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