Determining Prognosis: Patients with End-Stage Neurologic Disease (Reading & Sharing)

The three major subgroups: Alzheimer’s disease and other dementia, cerebrovascular disease, and amyotrophic lateral sclerosis (ALS) and related motor neuron disorders.

Alzheimer’s disease and other dementia

• • Inability to ambulate without assistance (FAST 7-C)
  • inability to speak or communicate meaningfully with speech limited to approximately a half-dozen or fewer intelligible or different words (FAST 7-B)
  • Loss of ADL functions including bathing and dressing (FAST 6)
  • Incontinence of bowel and bladder (FAST 6)
  • one or more of the following comorbid conditions in last 3-6 months
    • Aspiration pneumonia
    • Pyelonephritis or upper urinary tract infection
    • Septicemia
    • Decubitus ulcers, usually multiple and stages II or IV
    • Fever, recurrent after antibiotics
    • An altered nutritional status as manifested by:
      • difficulty swallowing or refusal to eat such that sufficient fluid or caloric intake cannot be maintained and the patient refuses artificial nutritional support
      • OR
      • If the patient is receiving artificial nutritional support (NG or G-tube or parenteral hyperalimentation), there must be evidence of an impaired nutritional status as defined in the General Guidelines (greater or equal 10% loss of body weight)

Cerebrovascular disease:

• Acute cerebrovascular disease and coma
  • Patient has one of the following conditions for at least 3 days duration:
    • coma
    • persistent vegetative status
    • severe obrundation accompanied by myoclonus
    • postanoxic stroke
  • Other factors associated with a high risk of mortality after 3 days
    • abnormal brainstem response
    • absent verbal response
    • absent withdrawal response to pain
    • serum creatinine greater or equal 1.5
    • age greater or equal 70 years
• Chronic cerebrovascular disease, coma, and persistent vegetative status (PVS)
  • Poststroke or multi-infarct dementia consistent with FAST 7, if patient not comatose or in PVS
  • Patient has had one ore more of the following comorbid conditions in the last 3-6 months:
    • Aspiration pneumonia
    • Pyelonephritis or upper urinary tract infection
    • Septicemia
    • Decubitus ulcers, usually multiple and stages II or IV
    • Fever, recurrent after antibiotics
    • An altered nutritional status as manifested by:
      • difficulty swallowing or refusal to eat such that sufficient fluid or caloric intake cannot be maintained and the patient refuses artificial nutritional support
      • OR
      • If the patient is receiving artificial nutritional support (NG or G-tube or parenteral hyperalimentation), there must be evidence of an impaired nutritional status as defined in the General Guidelines (greater or equal 10% loss of body weight)

Amyotrophic lateral sclerosis (ALS) and other forms of motor neuron disease:

• Rapid progression of ALS
  • Development of severe neurologic disability over a 12-month period. Examples include:
    • Progression from independent ambulation to wheelchair or bed bound
    • Progression from normal to barely intelligible or unintelligible speech
    • Progression from normal to blenderized diet
    • Progression from independence in most or all ADLs to needing major assistance in all ADLs
• Critically impaired ventilatory capacity
  • Vital capacity <30% predicted
  • Significant dyspnea at rest
  • supplemental oxygen needed at rest
  • refusal by patient of intubation, tracheostomy, other forms of mechanical ventilatory support
  • Note: If patient is already on some form of ventilatory support, he or she may still be appropriate for hospice or palliative care management if he or she exhibits one or more comorbid conditions as delineated below.
• Critical nutritional impairment
  • Difficulty swallowing or refusal to eat such that sufficient fluid or caloric intake cannot be maintained and the patient refuses artificial nutritional support
  • OR
  • If the patient is receiving artificial nutritional support (NG or G-tube or parenteral hyperalimentation), there must be evidence of an impaired nutritional status as defined in the General Guidelines (greater or equal 10% loss of body weight), as the patient should be experiencing continued weight loss despite feedings.
• Comorbid conditions
  • Aspiration pneumonia
  • Pyelonephritis or upper urinary tract infection
  • Septicemia
  • Decubitus ulcers, usually multiple and stages II or IV
  • Fever, recurrent after antibiotics