Context Many individuals involved with care of the dying advocate expanding
access to hospice care for persons with advanced lung, heart, or liver disease.
However, to be eligible, these patients generally must have a prognosis for
survival of less than 6 months.
Objective To test the ability of currently available criteria to identify a population
with a survival prognosis of 6 months or less among seriously ill hospitalized
patients with 1 of 3 commonly fatal chronic diseases.
Design Validation study using data from the Study to Understand Prognoses and
Preferences for Outcomes and Risks of Treatments (SUPPORT) phase 1 (June 1989-June
1991) and phase 2 (January 1992-January 1994), with a 6-month follow-up.
Setting and Patients Consecutive sample of 2607 seriously ill patients from 5 US medical
centers who were hospitalized with chronic obstructive pulmonary disease,
congestive heart failure, or end-stage liver disease, and who survived to
Main Outcome Measures Descriptive and operating characteristics of 5 general and 2 disease-specific
clinical criteria for identifying patients with a survival prognosis of 6
months or less, and 3 sets of combination criteria (broad, intermediate, and
narrow inclusion) aimed at providing low, medium, and high thresholds for
hospice eligibility based on National Hospice Organization guidelines.
Results Seventy-five percent of the sample survived more than 6 months after
hospital discharge; 44% expressed a preference for palliative care. Broad
inclusion criteria identified 923 patients eligible for hospice care, of whom
70% survived longer than 6 months. Intermediate inclusion criteria identified
300 patients, of whom 65% survived longer than 6 months. Narrow inclusion
criteria identified 19 patients, of whom 53% survived longer than 6 months.
Sensitivities and specificities of the combination criteria were 41.7% and
66.7% (broad inclusion), 16.2% and 90.1% (intermediate inclusion), and 1.4%
and 99.5% (narrow inclusion), respectively.
Conclusions These data indicate that for seriously ill hospitalized patients with
advanced chronic obstructive pulmonary disease, congestive heart failure,
or end-stage liver disease, recommended clinical prediction criteria are not
effective in identifying a population with a survival prognosis of 6 months