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Impact of prognosis on selected clinical decisions

Impact of prognosis on selected clinical decisions
Prognosis Condition Clinical decision to be considered
<4 to 6 weeks Depression at end of life Use methylphenidate to treat depression instead of a selective serotonin reuptake inhibitor (SSRI) as SSRIs require 4 to 6 weeks to take effect[1]
<3 months Hyperlipidemia Discontinuation of statins[2,3]
>3 months Spinal metastases Surgery for spinal cord compression due to metastatic cancer[4]
<6 months Hospice Referral to hospice
<1 to 2 years Asymptomatic abdominal aortic aneurysm Nonoperative management of asymptomatic abdominal aortic aneurysm[5-8]
<2 to 3 years Prevention macrovascular complications in diabetes mellitus Blood pressure/lipid control in diabetes mellitus unlikely to prevent macrovascular complications[9]
<2 to 3 years Hypertension Lowering blood pressure <140/80 unlikely to improve cardiovascular outcomes[2,10]
<5 years Screening for breast cancer Discontinuation of breast cancer screening[11-14]
<5 years Heart valve replacement Stented bioprosthetic heart valve may be preferable to a metallic valve[15]
<10 years[16] Glycemic control in diabetes Limited benefit to lowering target for A1C to <8%[2,9]
<7 years Screening for colorectal cancer Discontinuation of colorectal cancer screening[11,17-19]
<8 years Prevention microvascular complications in diabetes Tight glycemic control in diabetes mellitus is unlikely to prevent microvascular complications[2,9,20,21]
References:
  1. Block SD. Perspectives on care at the close of life. Psychological considerations, growth, and transcendence at the end of life: the art of the possible. JAMA 2001; 285:2898.
  2. Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006; 166:605.
  3. Vollrath AM, Sinclair C, Hallenbeck J. Discontinuing cardiovascular medications at the end of life: lipid-lowering agents. J Palliat Med 2005; 8:876.
  4. Abrahm JL, Banffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: "all I care about is walking and living my life". JAMA 2008; 299:937.
  5. Fillinger M. Who should we operate on and how do we decide: predicting rupture and survival in patients with aortic aneurysm. Semin Vasc Surg 2007; 20:121.
  6. Conway KP, Byrne J, Townsend M, Lane IF. Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited? J Vasc Surg 2001; 33:752.
  7. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA 2002; 287:2968.
  8. Mohan IV, Harris PL. When not to operate for abdominal aortic aneurysms. Semin Interv Cardiol 2000; 5:15.
  9. Brown AF, Mangione CM, Saliba D, Sarkisian CA. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003; 51:S265.
  10. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358:1887.
  11. Walter LC, Lewis CL, Barton MB. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. Am J Med 2005; 118:1078.
  12. Warner E. Clinical practice. Breast-cancer screening. N Engl J Med 2011; 365:1025.
  13. Breast cancer screening in older women. American Geriatrics Society Clinical Practice Committee. J Am Geriatr Soc 2000; 48:842.
  14. U.S. Preventive Services Task Force: Screening for Breast Cancer. U.S. Preventive Services Task Force 2009.
  15. Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010; 55:2413.
  16. Mulhausen P, Chun A, Green A, et al. American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc 2013;61:622-631.
  17. Walter LC, Lindquist K, Nugent S, et al. Impact of age and comorbidity on colorectal cancer screening among older veterans. Ann Intern Med 2009; 150:465.
  18. Colon cancer screening (USPSTF recommendation). U.S. Preventive Services Task Force. J Am Geriatr Soc 2000; 48:333.
  19. U.S. Preventive Services Task Force: Screening for Colorectal Cancer. U.S. Preventive Services Task Force 2008.
  20. Huang ES, Zhang Q, Gandra N, et al. The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: a decision analysis. Ann Intern Med 2008; 149:11.
  21. Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA Diabetes Trials: a position statement of the American Diabetes Association and a Scientific Statement of the American College of Cardiology Foundation and the American Heart Association. J Am Coll Cardiol 2009; 53:298.
Modified with permission from: Yourman LC, Lee SJ, Schonberg MA, et al. Prognostic indices for older adults. A systematic review. JAMA 2012; 307:182. Copyright © 2012 American Medical Association. All rights reserved.
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