Predicting End of Life: de Anna Looper, RN CHPN

PREDICTING END OF LIFE
De Anna Looper, RN CHPN

Corporate Clinical Consultant / Legal Nurse Consultant
Carrefour Associates L.L.C.

PREDICTING END OF LIFE
Predicting someone’s death can be nearly impossible. And, there isn’t a physician who hasn’t
been asked that question at one time or another. Coming up with a realistic answer is harder
than anyone could imagine.
There is a great book, on the market, CMS has established the Local
written by a physician who practices on the Determination Coverage policies (LCD),
East Coast. He tells the story of an animal which simply are clinical indicators to help
that can “predict” death. This physician determine a terminal prognosis. Many of the
works with patients residing in a long-term diseases have specific indicators that help
care facility and has to answer the question, determine a poor prognosis. For example,
“how long does he/she have doc? In this Alzheimer’s disease patients typically will
beautifully written story, the physician have a change in their functional status;
explains how this animal has an uncanny their speech is limited or nonsensical. They
ability to predict when a person is going to have an impaired ambulatory status such as
die. When the animal shows up in the requiring the use of a wheelchair when they
patient’s room, and takes residence, the previously utilized a walker, or now require a
animal will lie at the foot of the patient’s bed walker when they were previously
until they take their last breath. Once this independent. They have dysphagia and may
occurs, the animal meanders away, not to require thickened liquids to prevent choking.
be seen, for days at a time. The strange
In patients without a clear-cut diagnosis,
thing is that the patient has died almost
this becomes more difficult. Failure to thrive
every time the animal did this.
(otherwise known as Debility) is vaguer and
In hospice, we hear the same question, may be more difficult to determine. The
however, we don’t have a special animal to criteria for this diagnosis includes weight
predict when a patient’s time is near. We loss, change in functional status, and if they
too struggle with the answer. We can look have other co morbid conditions, this too
for clinical indicators, such as mottling, contributes to their poor prognosis.
apnea, a decrease in intake and/or output.
But to pinpoint or determine when a patient
has a terminal prognosis of “six months or
less” can be tricky.
Some of the simple signs that may indicate To simplify the process, when a physician
a poor prognosis include weight loss, a suspects that a patient may be exhibiting
change in intake, and change in continence. changes in their overall condition, they may
Other indicators include a change in be exhibiting a limited prognosis and a
functional or mental status, frequent hospice evaluation may be warranted. When
infections, skin impairment, refusing meals a patient begins to fail to respond to
or medications. Chronic UTI’s that fail to traditional treatment, or when the patient or
respond to antibiotics are another common patient’s family decide that “enough is
indicator. Something not commonly enough,” hospice should be contacted.
considered includes obesity. Obesity comes Offering compassionate palliative care
with its own unique medical issues, which throughout the end of life is one of the best
have been associated with end of life. And of gifts that a physician can give their patients.
course, there is the patient that no scientific
Although very few of us have an animal to
reason can explain their demise. The patient
help us predict the end of life, there are
may have simple ‘given up.’ Many patients
other ways that are just as successful as the
comment that they “are just sick and tired
animal with the innate ability to determine
of being sick and tired”.
death. Hospice is one of those avenues that
Even when using these LCD’s, determining a a physician can take. Offering peace,
six months prognosis still fails to be an comfort, dignity and compassion during the
exact science. The positive in all of this is final six months of life is not only a gift,
the fact that CMS also realizes that it’s the patient’s right.
determining a six-month prognosis is
If you have any questions or would like to
difficult and will not “punish” a physician for
order a hospice evaluation for a patient,
referring a patient to hospice once the
Crossroads Hospice can assist you in
physician feels the patient may be at the
determining if the patient is indeed,
end of life. The CMS guidelines clearly state
at the end of life.
that “a patient may not meet all or any of
the criteria and still qualify for hospice
services.” This is when it may be necessary
to call in a hospice representative to perform
a thorough review of the medical records
and perform an assessment to ascertain if
the patient exhibits a poor prognosis and
would qualify for hospice services.
1-888-603-MORE (6673) • www.CrossroadsHospice.com June 2010

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PREDICTING END OF LIFE

De Anna Looper, RN CHPN

Carrefour Associates L.L.C.

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