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It is of vital importance to face your mortality with a little common sense. And it is poorly understood that often the less you do to the frail the better the outcome.
Appalling! Whatever happened to good health care and the Hippocratic Oath? It's all about saving $$$$ and getting rid of the useless older, chronically ill, and disabled persons. Don't forget...that will be you one of them some day!
We need to be a little smarter about how we take care of older adults. Sending them for every test on the planet when their life expectancy is a year or two simply doesn't make sense (and it happens every day). Having a tool to help clinicians prognosticate will help everyone make better decisions.
From some of the previous comments, it seems as if some people do not understand that your system is meant to help people make decisions, not make decisions for them. As long as that distinction is maintained, I think this tool and others like it can be very useful. I think problems will occur if this model (or any other) becomes the de facto and only basis for making care decisions, concerns that some have expressed. Regardless, please accept my congratulations for this achievement. Well done.
An interesting approach to using evidence in practice. Could be very useful. I do think you should include links to the articles that are the basis for the scales. Those researchers and clinicians did the seminal work, and their efforts should be recognized and the papers available for interested readers.
My mother in-law is 91 and has dementia. Her frail 70 year old daughter doesn't want to put her in a facility because she's afraid the money will run out. Having some kind of idea about how long she will live is essential to planning for her care. Thank you for this!
It really isn't very clear how to use the tool even after looking at the FAQ
Do you click on some random circle and then work through the questions?
It might be more helpful if the starting point should be the questions not the graph.
Thanks for the great work - clearly by some of the comments people are still very uncomfortable with this type of conversation and this gets people started.
Having spent the last 30 years as an internist and geriatrician it is wonderful to see that internet tools are now available to younger and non geriatric physicians that will assist them in appropriate patient focused care. All of my non demented 85 year old patients clearly understood that premature death was no longer an option. They also understood the helpfulness and limits of modern medicine. Unfortunately, many of my subspecalty consultants did not.
Have you considered the CHADS model: Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001). Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 285 (22): 2864–70.
Stanley A. Terman, PhD, MD www.CaringAdvocates.org Carlsbad, CA 92009
This new tool will be very helpful for health professionals, enabling choosing among several possibilities the most appropriate life expectancy calculator. It offers various scientifically based options of variable quality. But these choices will be difficult to understand for lay people. Most are likely to fake an MD, hence the indexes are likely to become ill-used and misinterpreted. Maybe, there should be an explanatory paragraph in the Mode of Use, warning more clearly.
I see this as the beginning of medical rationing just like in some other countries such as the UK. "You are going to die anyway in a year so you don't get the treatment".
I see a lot of very miserable elders who will die painfully because of these kinds of "tools" that tell Dr. what kind of treatment they should have or not have.
This is very dangerous! Why not just pass a law that says "if you are over 70 you cost too much for our medical system, so you have to die"!
Congratulations to the team for taking the first steps to develop a rational and useful tool for geriatric medical practicioners. Much more work needs to be done. Those panicked and hysterical reactions from some of the public, based on their religious and/or political orientations, are to be expected, are not those of serious thinkers and professionals.
Of course this is an area with several ethical flashpoints and it would be possible to use the guides to thoughtlessly ration services, or further, to create a pool of 'medically futile' tests and treatments no longer to be delivered to certain populations, which are subject to covert racism, or gender, economic and/or personality issues. Having acknowledged that, most clinicians and many in the public can give examples of medical torture, deprivation of support services or egregious economic waste perpetrated by clinicians whose judgment is clouded by their own prejudices about what is in the best interest of the patient or what is 'morally correct'. 'Doing no harm' also includes not inflicting unnecessary procedures and tests nor economically draining patient and family resources in cases where this goes against patient wishes. Efforts to determine when patients might be ready for hospice services or when patients can be offered choices while being able to consider the probable long term benefits and short term sequellae are necessary to good and compassionate medical and nursing care.
This looks very helpful for supporting decision-making for my 92 year old Mom, however, I can't actually find the calculator on your website. Where do I look for the indicators?
I believe this is a tool for the benefit of insurance companies that would like to limit benefits for the elderly. If a treatment or therapy may ehance the quality of life, it should not be denied to any patient. For instance, withholding antibiotics for someone who may (or may NOT) die in six months is just cruel. Providing the best quality of life for all patients should be the goal. And this tool does not provide an certain estimate of life expectancy.
Probabilities define populations and not individuals. If you are a physician who is committed to the person in front of you and not to making sure that an insurance company is profitable in the current fiscal quarter then this is not the tool for you. If you are the latter, then shame on you.
I fail to see any relationship between these clinical tools and health care rationing. It is no different than the multitude of other assessments and tests used by physicians and nurses to evaluate patients. These tools will assist in providing the highest quality of care for an individual patient. They are not used in isolation, but rather as a very valuable supplement to assist patients and families in making choices that are consistent with their own goals and priorities. Rather than dictating to patients the care that must be provided, these tools will stimulate discussion of how the patient wants to live during the time he/she has left. The tools will provide more choices rather than less and the care will be more individualized according to the patient's desires.
It is time for realism when our organs begin to fail and we become burdens to others as well as ourselves. The workers in homes for the aged call them "Death Houses" and they say once you go in you do not come out. I, myself, want to be more than a pound of hamburger.
Intent of Question #1 is not clear. Perhaps it would be clearer to say: If patient was admitted to care home facility within the last 3 months, answer "Yes." If patient has not been admitted or such a facility, or was admitted more than 90 days ago, answer "No."
....unless you are really trying to pinpoint just the past three months and do not want a "Yes" regarding patients who were admitted 4 months ago, or six months, or longer.
It seems that we have an amount of paranoia in these comments. Someone commented that this would be similar to the UK. I have an 87 year old sister living in the UK and she gets excellent care.She's been in the hospital a few times in the past year because of her COPD but when she returns home nursing care is available for her when needed - in the home. This is the NHS which Americans abhor. As someone else mentioned: is a BMI above 25 indicative of a longer life?
Very helpful. I think that people who don't work in geriatrics do not understand that, sometimes, the less intervention, the longer your patients live, and with better quality of life. It's not about saving money, it's about decreasing suffering. An NP
Once people get over the paranoia, by realizing that everyone dies sometime, they may be able to have a sensible discussion about is it better to perform 1 heart transplant on a very frail individual who may not survive the surgery or buy 10 kidney dialysis machines to extend the life for the not so frail. money is a finite resource and should be put to the best use, and whether people like it or not these decisions go on currently everyday, but in a non transparent way.
As a 66 year old I find this comforting. A doctor can apply some statistical analysis to what may be unnecessary and unhelpful treatments for me based on known factors in my health. That's a good thing. I am more afraid of doctors over-medicating, or doing unnecessary surgeries than I am of being denied treatments. We all have fears about survival, but it comes through our individual philosophy about the inevitable, which is death. I hope I have a doctor who will be forthright in discussions with me educating me about how s/he arrives at my healthcare reccomendations.
I didn't find this very useful. I am 81 years of age and have multiple health problems. I would like an idea of my life expectancy. I wear a do not resuscitate tag and do not wish my life extended with any extraordinary means. I've talked with my doctor about palative care and then hospice. She won't make a guess as to how long I will live which is prudent on her part. I like her and she will respect my wishes. If I live another 10 years, my health care will be so expensive that I will be out of money. Do you have a patient chart for predicting end of life? Sincerely, JAF----janashf@surewest.net .R.N.; PHN
Interesting. I look forward to using it. Unfortunately, the calculators do not appear nor function properly via Firefox, although they seem to work on iPhone. Beth M Saltzman MD
I found the scales helpful for informing the decisions we are making with some idea of possible timelines. We work closely with our family physician. These guidelines are not too far away from what she tells us. I welcome the gathering of this type of information for both the general population, and the truly frail elderly (>85).
I assume there is a mistake in the wording of question four in the Schonberg Index. An answer of yes to - “Does your patient have a BMI score of less than 25?” - adds two points to a patient’s score. Zero points are added for an answer of no. This means a patient with a BMI of greater than 25 - pre-obesity, a known risk factor of developing diabetes, cardiovascular disease, cancers, sleep apnea - has a better prognosis than a patient of normal weight. Am I right that this is a mistake?
To anonymous above, thank you for a great question. The wording of the question in the Schonberg index is correct. In old age, higher BMI is protective. This may be because lower BMI is a sign of disease, rather than obesity being protective.
To the anonymous above - thanks for pointing out typos...morality index instead of mortality index, that was a good one!
Please keep the comments coming, we'll try to be more responsive to them going forward.
a necessary dialog 4 this time and age. i dread facing failing health, hospitals, surgeries, loss of bodily functions, extended mental & physical pain & suffering, loss of dignity, loss of what little $$$ i may still have 2 pass along 2 family.
my wish is 2 b as informed as possible as 2 end of life. wish i did not have 2 move 2 OR, WA or MT 4 physician asst'd end of life when the time is at hand.
Excellent tools for educating (i.e., a dose of reality) both care givers and patients. As a former HIV epidemiologist and educator, I often asked coworkers and students to define "untimely death." Using these estimators of life expectancy could help put some boundaries on that question. I, too, am concerned about using a single BMI cut point rather than the patient's actual BMI. Also, would the stage of any melanomas make a difference?
interesting but way too negative. doesnt consider type of cancer, recurrance, or life style measures such as exercise, stress control, diet etc. dharma singh khalsa, md
Too general to be of any use. For example, BMI doesn't consider a person who is muscular having been an athlete and exercised consistently for 60 years. If I lost 10 pounds and got down to my football playing weight, I'd still have a BMI of 26+. This system doesn't consider family history, parents age. If both parents lived to 90+ that should be a genetic factor. Hospitalization in the past year is too general. Why should knee replacement surgery be a risk factor?
As a geriatrician, this provides a useful tool to help with the dialogue on discussing various screening modalities and to give the patient an idea about life expectancy. Thanks for the resource!
suggest make clear that schonberg calculates 5 and 9 year mortality not just 5 (don't see the 9 year until you get into calculator). Site is great help
I'd like it if the post a comment box was at the top. Also, would be nice if there is a print function at the bottom of each page after you get the estimation. Or a place to write in your own estimation.
otherwise, really like the layout in terms of incorporating my best guess before i see the calculation. makes sure that these calculations won't be interpreted without clinical judgment.
En mi país, Chile, usamos mucho esta página en nuestro trabajo diario como geriatras. Los felicito y les agradezco el maravilloso trabajo que han hecho. Claro y preciso. Gracias!!!!
54 comments:
trash
It was few stupid guys use stupid logic
It is of vital importance to face your mortality with a little common sense. And it is poorly understood that often the less you do to the frail the better the outcome.
Appalling! Whatever happened to good health care and the Hippocratic Oath? It's all about saving $$$$ and getting rid of the useless older, chronically ill, and disabled persons. Don't forget...that will be you one of them some day!
How soon before this defines funding for care benefits?
Why does having a BMI greater than 25 result in a longer life span according to these models.
We need to be a little smarter about how we take care of older adults. Sending them for every test on the planet when their life expectancy is a year or two simply doesn't make sense (and it happens every day). Having a tool to help clinicians prognosticate will help everyone make better decisions.
Dear Team,
From some of the previous comments, it seems as if some people do not understand that your system is meant to help people make decisions, not make decisions for them. As long as that distinction is maintained, I think this tool and others like it can be very useful. I think problems will occur if this model (or any other) becomes the de facto and only basis for making care decisions, concerns that some have expressed. Regardless, please accept my congratulations for this achievement. Well done.
It smells of 'economic rationalists' deciding on health funding, yet again, to no one's benefit.
An interesting approach to using evidence in practice. Could be very useful. I do think you should include links to the articles that are the basis for the scales. Those researchers and clinicians did the seminal work, and their efforts should be recognized and the papers available for interested readers.
My mother in-law is 91 and has dementia. Her frail 70 year old daughter doesn't want to put her in a facility because she's afraid the money will run out. Having some kind of idea about how long she will live is essential to planning for her care. Thank you for this!
It really isn't very clear how to use the tool even after looking at the FAQ
Do you click on some random circle and then work through the questions?
It might be more helpful if the starting point should be the questions not the graph.
Thanks for the great work - clearly by some of the comments people are still very uncomfortable with this type of conversation and this gets people started.
Having spent the last 30 years as an internist and geriatrician it is wonderful to see that internet tools are now available to younger and non geriatric physicians that will assist them in appropriate patient focused care. All of my non demented 85 year old patients clearly understood that premature death was no longer an option. They also understood the helpfulness and limits of modern medicine. Unfortunately, many of my subspecalty consultants did not.
Have you considered the CHADS model: Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001). Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 285 (22): 2864–70.
Stanley A. Terman, PhD, MD
www.CaringAdvocates.org
Carlsbad, CA 92009
Exactly how do I use this tool? And there are several life expectancy calculators on the web; just Google for that...
This new tool will be very helpful for health professionals, enabling choosing among several possibilities the most appropriate life expectancy calculator. It offers various scientifically based options of variable quality.
But these choices will be difficult to understand for lay people. Most are likely to fake an MD, hence the indexes are likely to become ill-used and misinterpreted. Maybe, there should be an explanatory paragraph in the Mode of Use, warning more clearly.
Alain de Weck, MD
Switzerland
I see this as the beginning of medical rationing just like in some other countries such as the UK. "You are going to die anyway in a year so you don't get the treatment".
I see a lot of very miserable elders who will die painfully because of these kinds of "tools" that tell Dr. what kind of treatment they should have or not have.
This is very dangerous! Why not just pass a law that says "if you are over 70 you cost too much for our medical system, so you have to die"!
Congratulations to the team for taking the first steps to develop a rational and useful tool for geriatric medical practicioners. Much more work needs to be done. Those panicked and hysterical reactions from some of the public, based on their religious and/or political orientations, are to be expected, are not those of serious thinkers and professionals.
Of course this is an area with several ethical flashpoints and it would be possible to use the guides to thoughtlessly ration services, or further, to create a pool of 'medically futile' tests and treatments no longer to be delivered to certain populations, which are subject to covert racism, or gender, economic and/or personality issues. Having acknowledged that, most clinicians and many in the public can give examples of medical torture, deprivation of support services or egregious economic waste perpetrated by clinicians whose judgment is clouded by their own prejudices about what is in the best interest of the patient or what is 'morally correct'. 'Doing no harm' also includes not inflicting unnecessary procedures and tests nor economically draining patient and family resources in cases where this goes against patient wishes.
Efforts to determine when patients might be ready for hospice services or when patients can be offered choices while being able to consider the probable long term benefits and short term sequellae are necessary to good and compassionate medical and nursing care.
This looks very helpful for supporting decision-making for my 92 year old Mom, however, I can't actually find the calculator on your website. Where do I look for the indicators?
I believe this is a tool for the benefit of insurance companies that would like to limit benefits for the elderly. If a treatment or therapy may ehance the quality of life, it should not be denied to any patient. For instance, withholding antibiotics for someone who may (or may NOT) die in six months is just cruel. Providing the best quality of life for all patients should be the goal. And this tool does not provide an certain estimate of life expectancy.
The comments indicate a high degree of paranoia in American society.
Probabilities define populations and not individuals. If you are a physician who is committed to the person in front of you and not to making sure that an insurance company is profitable in the current fiscal quarter then this is not the tool for you. If you are the latter, then shame on you.
I am not able to view the tools. It says my "browser does not support canvas HTMLS" What does this mean and how can I fix it?
I fail to see any relationship between these clinical tools and health care rationing. It is no different than the multitude of other assessments and tests used by physicians and nurses to evaluate patients. These tools will assist in providing the highest quality of care for an individual patient. They are not used in isolation, but rather as a very valuable supplement to assist patients and families in making choices that are consistent with their own goals and priorities. Rather than dictating to patients the care that must be provided, these tools will stimulate discussion of how the patient wants to live during the time he/she has left. The tools will provide more choices rather than less and the care will be more individualized according to the patient's desires.
Sharon is right. What most people don't realize is that today doctors make these decisions every day without tools. Why not give them some help.
It is time for realism when our organs begin to fail and we become burdens to others as well as ourselves.
The workers in homes for the aged call them "Death Houses" and they say once you go in you do not come out.
I, myself, want to be more than a pound of hamburger.
The BMI question in the Schonberg Index is incorrect in that it adds points for having a BMI less than 25. It should do the opposite.
I was most disappointed to be unable to access your tool. The HELP button was no help, either. Suggestions?
Another waste of research funds by self-serving scientists. This is why science has lost credibility.
Intent of Question #1 is not clear. Perhaps it would be clearer to say: If patient was admitted to care home facility within the last 3 months, answer "Yes." If patient has not been admitted or such a facility, or was admitted more than 90 days ago, answer "No."
....unless you are really trying to pinpoint just the past three months and do not want a "Yes" regarding patients who were admitted 4 months ago, or six months, or longer.
It seems that we have an amount of paranoia in these comments. Someone commented that this would be similar to the UK. I have an 87 year old sister living in the UK and she gets excellent care.She's been in the hospital a few times in the past year because of her COPD but when she returns home nursing care is available for her when needed - in the home. This is the NHS which Americans abhor.
As someone else mentioned: is a BMI above 25 indicative of a longer life?
Very helpful. I think that people who don't work in geriatrics do not understand that, sometimes, the less intervention, the longer your patients live, and with better quality of life. It's not about saving money, it's about decreasing suffering. An NP
Where is you patient?
I found this when I clicked the "Calculator". Shouldn't it say, "Where is your patient?"
Schonberg calculator calculates based on "morality" versus "mortality". Nice...
(5 year morality = Schonberg Index)
Is it really likely that a person 101 now has a 58% chance of living another 9 years?
Please fix typos.
Once people get over the paranoia, by realizing that everyone dies sometime, they may be able to have a sensible discussion about is it better to perform 1 heart transplant on a very frail individual who may not survive the surgery or buy 10 kidney dialysis machines to extend the life for the not so frail.
money is a finite resource and should be put to the best use, and whether people like it or not these decisions go on currently everyday, but in a non transparent way.
As a 66 year old I find this comforting. A doctor can apply some statistical analysis to what may be unnecessary and unhelpful treatments for me based on known factors in my health. That's a good thing. I am more afraid of doctors over-medicating, or doing unnecessary surgeries than I am of being denied treatments. We all have fears about survival, but it comes through our individual philosophy about the inevitable, which is death. I hope I have a doctor who will be forthright in discussions with me educating me about how s/he arrives at my healthcare reccomendations.
I didn't find this very useful. I am 81 years of age and have multiple health problems. I would like an idea of my life expectancy. I wear a do not resuscitate tag and do not wish my life extended with any extraordinary means. I've talked with my doctor about palative care and then hospice. She won't make a guess as to how long I will live which is prudent on her part. I like her and she will respect my wishes.
If I live another 10 years, my health care will be so expensive that I will be out of money. Do you have a patient chart for predicting end of life?
Sincerely,
JAF----janashf@surewest.net .R.N.; PHN
Interesting. I look forward to using it. Unfortunately, the calculators do not appear nor function properly via Firefox, although they seem to work on iPhone.
Beth M Saltzman MD
I found the scales helpful for informing the decisions we are making with some idea of possible timelines. We work closely with our family physician. These guidelines are not too far away from what she tells us. I welcome the gathering of this type of information for both the general population, and the truly frail elderly (>85).
I assume there is a mistake in the wording of question four in the Schonberg Index. An answer of yes to - “Does your patient have a BMI score of less than 25?” - adds two points to a patient’s score. Zero points are added for an answer of no. This means a patient with a BMI of greater than 25 - pre-obesity, a known risk factor of developing diabetes, cardiovascular disease, cancers, sleep apnea - has a better prognosis than a patient of normal weight. Am I right that this is a mistake?
To anonymous above, thank you for a great question. The wording of the question in the Schonberg index is correct. In old age, higher BMI is protective. This may be because lower BMI is a sign of disease, rather than obesity being protective.
To the anonymous above - thanks for pointing out typos...morality index instead of mortality index, that was a good one!
Please keep the comments coming, we'll try to be more responsive to them going forward.
Thank you for an excellent site. Markers of inflammation may improve the risk score, such as suPAR, suPARnostic.com and perhaps hsCRP
Why is the wealth factor not considered in any of these?
http://finance.yahoo.com/news/rich-people-live-longer-161138978.html
a necessary dialog 4 this time and age. i dread facing failing health, hospitals, surgeries, loss of bodily functions, extended mental & physical pain & suffering, loss of dignity, loss of what little $$$ i may still have 2 pass along 2 family.
my wish is 2 b as informed as possible as 2 end of life.
wish i did not have 2 move 2 OR, WA or MT 4 physician asst'd end of life when the time is at hand.
Excellent tools for educating (i.e., a dose of reality) both care givers and patients. As a former HIV epidemiologist and educator, I often asked coworkers and students to define "untimely death." Using these estimators of life expectancy could help put some boundaries on that question. I, too, am concerned about using a single BMI cut point rather than the patient's actual BMI. Also, would the stage of any melanomas make a difference?
interesting but way too negative. doesnt consider type of cancer, recurrance, or life style measures such as exercise, stress control, diet etc. dharma singh khalsa, md
Too general to be of any use. For example, BMI doesn't consider a person who is muscular having been an athlete and exercised consistently for 60 years. If I lost 10 pounds and got down to my football playing weight, I'd still have a BMI of 26+. This system doesn't consider family history, parents age. If both parents lived to 90+ that should be a genetic factor. Hospitalization in the past year is too general. Why should knee replacement surgery be a risk factor?
As a geriatrician, this provides a useful tool to help with the dialogue on discussing various screening modalities and to give the patient an idea about life expectancy. Thanks for the resource!
suggest make clear that schonberg calculates 5 and 9 year mortality not just 5 (don't see the 9 year until you get into calculator). Site is great help
I'd like it if the post a comment box was at the top. Also, would be nice if there is a print function at the bottom of each page after you get the estimation. Or a place to write in your own estimation.
otherwise, really like the layout in terms of incorporating my best guess before i see the calculation. makes sure that these calculations won't be interpreted without clinical judgment.
Thanks!
Lindsey Yourman :)
En mi país, Chile, usamos mucho esta página en nuestro trabajo diario como geriatras. Los felicito y les agradezco el maravilloso trabajo que han hecho. Claro y preciso. Gracias!!!!
I look forward in reading more of your work. Also, I made sure to bookmark your website so I can come back later.
The calculators do not work on my iPad. I hope an update will fix this.
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