Quality of life considerations

Intro to QoL - More Than a Pulse

Quality of Life (QoL) is a multidimensional concept assessing a patient's subjective perception of their well-being. It extends beyond mere absence of disease to include overall life satisfaction.

• Core Domains (WHO-QoL):

  • Physical Health (pain, energy)
  • Psychological (positive feelings, self-esteem)
  • Social Relationships (personal support)
  • Environment (safety, financial resources)

• Assessment: Crucial in chronic illness (cancer, heart failure) & palliative care. Tools include SF-36, EQ-5D.

⭐ In oncology, patient-reported QoL scores can be a stronger predictor of hospitalizations and survival than some objective tumour markers.

QoL Assessment - Scoring the Feeling

Quality of Life (QoL) is measured using validated scales. Performance status is a key proxy, especially in oncology.

⭐ ECOG 2 is a key threshold: Ambulatory and capable of self-care, but unable to carry out any work activities. Up and about more than 50% of waking hours.

Prioritizing Interventions - The Balancing Act

Balancing life extension with Quality of Life (QoL) is a central clinical skill. The goal is to align medical interventions with the patient's values and overall well-being, not just survival.

• Core Metric: Quality-Adjusted Life Year (QALY) is a key measure.
  • $QALY = (Years of Life Gained) \times (Utility Value)$
  • Utility Value: A score from 0 (death) to 1 (perfect health) representing QoL.
• Key Considerations:
  • Patient Autonomy: Respecting the patient's goals and preferences.
  • Treatment Burden: Assessing the impact of side effects, financial cost, and time.
  • Prognosis: The likely outcome with and without the intervention.

⭐ A QALY of 1.0 represents a year in perfect health. Interventions are often evaluated based on their cost per QALY gained, guiding health policy and clinical choices.

Decision Flowchart:

Key Scenarios - Palliation & Geriatrics

• Goal Shift: Transition from curative intent to optimizing Quality of Life (QoL), prioritizing patient values and functional status.
• Palliative Principles:
  • Symptom Control: Use validated tools (e.g., ESAS). Address "total pain" (physical, psychological, social, spiritual).
  • Opioid Use: Follow WHO analgesic ladder. Morphine is key for pain/dyspnea.
  • Advance Care Planning: Document patient wishes via Living Will & Durable Power of Attorney for Healthcare.
• Geriatric Focus:
  • Frailty Assessment: Use Clinical Frailty Scale to guide intervention intensity.
  • De-prescribing: Systematically reduce polypharmacy to prevent adverse drug events.

⭐ The "Surprise Question" ("Would you be surprised if this patient died in the next year?") is a key trigger to initiate goals of care conversations.

High-Yield Points - ⚡ Biggest Takeaways

• In CCS cases, prioritize interventions enhancing Quality of Life (QoL), not just extending survival, especially in chronic or terminal illness.
• Use objective measures like QALYs (Quality-Adjusted Life Years) to balance longevity with well-being.
• The goal often shifts from curative treatment to symptom control and palliative care.
• Patient autonomy and shared decision-making are paramount when considering QoL.
• Consider the socio-economic impact and cost-effectiveness of interventions on the patient's life.