Annals of Long Term Care

Healthcare providers working in long term-care facilities are often called upon to make a judgment regarding a patient’s life expectancy. These judgments can be broadly broken down into three time frames: (1) Will a patient live long enough to benefit from a specific intervention directed at treating or preventing a disease or illness? (2) Is the patient’s life expectancy less than 6 months so that the patient can be considered for enrollment in Medicare-covered hospice? (3) Is the patient going to die so soon that family members should make arrangements now to visit the patient? This article discusses the determination of life expectancy in these three scenarios and references useful assessments for clinicians. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[4]:21-24)

Introduction
The effectiveness of many medical interventions is impacted by how long a patient is expected to live. Most healthcare providers do not apply an explicit calculation of life expectancy when deciding whether to begin a specific treatment or offer a patient a screening test. Most practitioners use implicit reasoning to make these decisions. Though physicians’ predictions of survival have been found to be highly correlated with actual survival, they have a tendency to overestimate survival.¹

Medicare-covered hospice requires that a physician certify that the patient is expected to die within 6 months.² Many healthcare providers hesitate and delay the initiation of hospice care because they don’t feel comfortable with their ability to make this determination.³ Healthcare providers are also reluctant to say when distant relatives and friends should make a final visit to a dying patient. Here again, providers are concerned that they will not make the correct judgment.

Estimates of life expectancy have an important impact on medical practice in long-term care (LTC) settings, and there are now growing bodies of data that can help the healthcare provider make a more accurate determination.

Long-Term Life Expectancy (more than 6 mo)
Most healthcare providers will not prescribe bisphosphonates for the treatment of osteoporosis when a patient has metastatic lung cancer. However, should an 85-year-old patient with osteoporosis and no apparent life-threatening illness be prescribed a bisphosphonate? To answer this question from an informed perspective, the healthcare provider needs to go through several steps (discussed below): (1) calculate the patient’s life expectancy; (2) determine how long the medication needs to be given before a benefit occurs; and (3) decide whether the benefit is clinically meaningful. Side effects and costs are additional considerations. Deciding when to stop screening for a disease requires a similar analysis. Many disease prevention guidelines now indicate that a screening test or intervention should be suspended only when the patient’s life expectancy is less than a certain number of years.⁴ Patients’ or their legal guardians’ wishes are a critical component of the decision-making process, especially when a patient or legal guardian decides not to proceed with a recommended treatment. In one study, a patient’s decision to have a ventricular assistive device placed to treat serious heart failure was influenced by estimated life expectancy and by predictions regarding quality of life with and without the intervention.⁵

Step 1. Estimating Life Expectancy
Life expectancy is affected by age, disease, and disability. Life expectancy tables list years of life expectancy at a certain age and are based on all-cause mortality.⁶ Although age is a strong predictor of mortality, disease is also important.