Over

4413 Oakwood Drive, Chattanooga, TN 37416 Phone: (423) 553-1823 Fax: (423) 553-1829

Palliative Care Appropriate Screening Tool

Section 1

Diagnosis: 2 points for each

____Dialysis dependent renal failure or need for acute dialysis

____Oxygen dependent COPD or Gold 3 and 4 criteria patients (FEV1<50%)

____Progressive or metastatic malignancy

____Severe neurological injury including CVA, trauma, anoxic encephalopathy

____CHF/CAD/cardiomyopathy ACE or NYC III or IV

____ICU patients not progressing after 5th day of mechanical ventilation (including BIPAP)

____2nd readmission for same diagnosis in last 60 days

____Liver failure with encephalopathy or major bleeding episode

____Other life limiting or serious progressive illness

Total Points Section 1______

Section 2

Modifiers and Situations: 1 point for each

____Transplant or organ donation being considered

____PEG, tracheostomy, AICD or other long term device placement being discussed (or already in place)

____Unrealistic or divergent family opinions about care (including not following advanced directives)

____No advanced directives, spokesperson or loss of primary care giver ability to continue care

____Complex situation or need for ongoing care coordination

____Uncontrolled or unsatisfactory symptom control of pain, nausea, delirium, etc, >24 hours

____Medical team and family unable to resolve conflicts regarding level of care, prognosis, etc.

Total points Section 2______

Section 3

“Surprise” Question: 2 points

Would you be surprised if patient died in next 12 months? (Yes=0 points; No=2 points)

Total points Section 3______

Add Points: Section 1____ +Section 2____ +Section 3_____ +Section 4____ =Total Points_______

Patients with total score > 5 should be considered for ASPIRE HEALTH TEAM CONSULT.

If in doubt, please contact our office to request a consult and we will be happy to provide an opinion.

Phone: (423) 553-1823 Fax: (423) 553-1829

Section 4

Functional Status of Patient

Eastern Cooperative Oncology Group (ECOG) Performance Status Scale

Grade Scale

1 Fully active able to carry on all pre-disease activities without restriction.

2 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g. light housework, office work).

3 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.

4 Capable of only limited self-care; confined to bed or chair more than 50% of waking hours.

5 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.

PPS

% Ambulation Activity and Evidence of Disease Self-Care Intake Consciousness Level

100 Full Normal Activity No evidence of Disease

Full Normal Full

90 Full Normal Activity Some evidence of Disease

Full Normal Full

80 Full Normal Activity with Effort Some evidence of Disease

Full Normal or

Reduced

Full

70 Reduced Unable Normal Job/Work Some evidence of Disease

Full Normal or

Reduced

Full

60 Reduced Unable Hobby/House Work Significant Disease

Occasional Assistance

Required

Normal or

Reduced

Full or Confusion

50 Mainly Sit

and/or Lie

Unable to Do Any Work Extensive Disease

Considerable

Assistance Required

Normal or

Reduced

Full or Confusion

40 Totally Bed

Bound

Unable to Do Any Work Extensive Disease

Mainly Assistance Normal or

Reduced

Full or Drowsy or

Confusion

30 Totally Bed

Bound

Unable to Do Any Work Extensive Disease

Total Care Reduced Full or Drowsy or

Confusion

20 Totally Bed

Bound

Unable to Do Any Work Extensive Disease

Total Care Minimal Sips Full or Drowsy or

Confusion

10 Totally Bed

Bound

Unable to Do Any Work Extensive Disease

Total Care Mouth Care

Only

Drowsy or Coma

0 Death

*This scale is a modification of the Karnofsky Performance Scale. It takes into account ambulation, activity, self-care, intake, and consciousness level.

ECOG=2 or PPS=70 (1 point) ECOG=3 or PPS=50/60 (2 points) ECOG=4 or PPS=30/40 (3 points)

Total Points Section 4_______

CRITERIA FOR PALLIATIVE CARE ASSESSMENT AT THE TIME OF HOSPITAL ADMISSION AND

DURING HOSPITAL STAY

At Time of Hospital Admission

Primary

criteria*

A potentially life-limiting or life-threatening condition AND

Not surprised if the patient died within 12 months

More than one admission for same condition within several months

Admission for difficult physical or psychologic symptoms

Complex care requirements (e.g., functional dependency, complex home support for

ventilator/antibiotics/feedings)

Failure to thrive (decline in function, feeding intolerance, or unintended decline in weight)

Secondary

criteria†

A potentially life-limiting or life-threatening condition AND

Admission from long-term care facility

Older age, with cognitive impairment and acute hip fracture

Metastatic or locally advanced incurable cancer

Chronic use of home oxygen use

Out-of-hospital cardiac arrest

Current or past hospice program use

Limited social support

No history of advance care planning discussion/document

During Hospital Stay

Primary

criteria*

A potentially life-limiting or life-threatening condition AND

Not surprised if the patient died within 12 months

More than one admission for same condition within several months

Stay in intensive care unit of 7 days or more

Lack of documentation of goals of care

Disagreements or uncertainty among the patient, staff, and/or family about major medical

treatment decisions, resuscitation preferences, or use of nonoral feeding or hydration

Secondary

criteria†

A potentially life-limiting or life-threatening condition AND

Awaiting, or deemed ineligible for, solid-organ transplantation

Patient/family/surrogate emotional, spiritual, or relational distress

Patient/family/surrogate request for palliative care/hospice services

Patient is a potential candidate for feeding tube placement, tracheostomy, initiation of renal

replacement therapy, placement of left ventricular assist device or automated implantable

cardioverter-defibrillator, bone marrow transplantation (high-risk patients)

*Primary criteria are the minimum indicators for screening patients at risk for unmet palliative care

needs.

†Secondary criteria are more specific indicators of a high likelihood of unmet palliative care needs.

COMMUNICATINGEnd-of-Life Wishes

HospiceIt’s About How You LIVE

When it comes to creating memories,the family is often at the heart

of sharing in life events.

We plan for weddings,

the birth of a child, going off to college,

and retirement. Despite the conversations

we have for these life events, rarely do we

have conversations about how we want to

be cared for at the end of our lives.

With roughly 2.4 million Americans dying

each year, it is important that personal

conversations take place about the kinds of

experiences you want for yourself and the

wishes of your loved ones before facing an

end-of-life situation. We know from

research that Americans are more likely to

talk to their children about safe sex and

drugs than to talk to their parents about

end-of-life care choices.

Communicating End-of-Life Wishes

Experts agree the time to discuss your views aboutend-of-life care, and to learn about the end-of-lifecare choices available, is before a life-limiting illnessoccurs or a crisis happens. By preparing in advance,you can help reduce the doubt or anxiety related tomaking decisions for your family member whenthey cannot speak for themselves.

Plan Ahead

The time to communicate end-of-life care wishesis now when you and your loved ones are still ableto discuss your choices. Review the steps below andshare them with your friends and family tocommunicate end-of-life wishes.

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COMMUNICATINGEnd-of-Life Wishes

COMMUNICATINGEnd-of-Life Wishes

3

The following are simple steps to ensure that end-of-life carewishes are followed:

� Draw up a living will of written instructions tocommunicate care and treatment wishes andpreferences in the event you cannot speak for yourself.

� Have a durable power of attorney in place that allowsa person of your choosing to make medical decisionsfor you if you become unable to do so.

Provide your family doctor with a copy of this document.Make sure to communicate your wishes to this person andmake sure that this person agrees to assume the responsibility.

Since every state has different laws it is important to use state-specific advance directives. Contact NHPCO to receive a

state-specific advance directive:www.caringinfo.org � caringinfo@nhpco.org

HelpLine 800.658.8898 � Multilingual Line 877.658.8896

Advance directives can be useful tools for making end-of-life carewishes known, however it is just as important to have personalconversations with family and loved ones about these issues.

Discuss Your Wishes Early

Discuss your end-of-life care wishes with family and loved onesnow — before a crisis happens. The following can be used asopportunities for having this conversation:

� Around significant life events, such as marriage, birthof a child, death of a loved one, retirement, birthdays,anniversaries, or college graduation

� While drawing up a will or doing other estate planning� When major illness requires that you or a family membermove out of your home and into a retirement community,nursing home, or other longterm care setting

� During holiday gatherings, such as Thanksgiving,when family members are present

� When a friend or another family member is facingillness or an end-of-life situation

Whenever possible, include your children in these conversa-tions, not just your parents, spouse or partner. It is never tooearly to start thinking about these issues. Have regulardiscussions about your views on end-of-life care, since they maychange over time. And don’t forget to discuss your end-of-lifecare wishes with your doctor. Here are a few helpful pointersto keep in mind as you plan for having this conversation:

1. Do Your HomeworkBefore beginning the discussion, learn about end-of- life careservices available in your community. Become familiar withwhat each option offers so you can decide which ones meetyour loved one or your own, end-of-life care needs and wants.

2. Select an Appropriate SettingPlan for the conversation. Find a quiet, comfortable placethat is free from distractions to hold a one-on-one discussionor family meeting. Usually, a private setting is best.

3. Ask PermissionPeople cope with end-of-life care issues in many ways.Asking permission to discuss this topic assures your lovedone that you will respect and honor his or her wishes.

Some ways of asking permission are:

“I’d like to talk about the best way someone might care for youif you got really sick. Is that okay?”

“If you ever got sick, I would be afraid of not knowing the kindof care you would like. Could we talk about this now? I’d feelbetter if we did.”

“I want to share my wishes about how I’d like to be cared for inthe event I was sick or injured; can we do that now?”

Another method of beginning the conversation is to sharean article, magazine, or story about the topic with yourloved one. Even watching a TV show or movie on thetopic together can encourage the conversation. If youthink your loved one would be more comfortable withsomeone else, you can suggest they talk to another familymember, a friend or faith leader.

4

Decide what you want for your own end-of-life care.

4. Begin the ConversationKeep in mind that you started this conversation becauseyou care about your loved one wellbeing — especiallyduring difficult times. Allow your loved one to set the pace.Nodding your head in agreement, holding your loved onehand, and reaching out to offer a hug or comforting touchare ways that you can show your love and concern.

Understand that it is normal for your loved ones to avoidthis discussion. Don’t be surprised or upset; instead, planto try again at another time.

Questions to ask your loved one about his or her end-of-life care:

“How would you like your choices honored at the end of life?”

“Would you like to spend your final days at home or in ahomelike setting?”

“Do you think it’s important to have medical attention andpain control to fit your needs?”

“Is it important for you — and your family — to haveemotional and spiritual support?”

If your loved one responds “yes” in answer to these questions,he or she may want the end-of-life care that hospice provides.

5. Be a Good ListenerKeep in mind that this is a conversation, not a debate.Sometimes just having someone to talk to is a big help. Besure to make an effort to hear and understand what theperson is saying. These moments, although difficult, areimportant and special to both of you.

Some important considerations:

� Listen for the wants and needs your loved one expresses.

� Make clear that what your loved one is sharing withyou is important.

� Show empathy and respect by addressing these wantsand needs in a truthful and open way.

� Acknowledge your loved one right to make lifechoices — even if you do not agree with them.

COMMUNICATINGEnd-of-Life Wishes

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6. Call HospiceIf you — or those you love — are struggling to cope witha life-limiting illness, help is available through hospice.Hospice programs provide quality care focusing on comfortand dignity for persons who are ill, and their loved ones.Here are some important things to know about hospice:

� Hospice provides a team of professionals that offerexpert medical care, pain management, andemotional and spiritual support to meet the needs andwishes of the person who is ill.

� Emotional support is also provided to the patient’sloved ones.

� Hospice focuses on aggressively treating pain orsymptoms to make the person as comfortable aspossible. Care is usually provided in the person’s home.

� Hospice also is provided in hospice facilities, hospitals,and nursing homes and other longterm care facilities.

� Hospice services are available to patients of any age,religion, race, or illness, regardless of their method ofpayment.

� Members of the hospice staff make regular visits toassess the person who is ill and provide extra care orother services. Hospice staff is on-call 24 hours a day,seven days a week.

� The hospice team — which includes the person whois ill, family/ carnegies, doctors, nurses, social workers,spiritual carnegies, counselors, home health aides, andtrained volunteers — develops a care plan that meetseach person’s individual needs for care and support.

� The care plan describes the services needed such asnursing care, personal care (dressing, bathing, etc.),emotional support, and doctor visits. It also identifies themedical equipment, tests, procedures, medication andtreatments necessary to provide high-quality comfort care.

� After death, hospice provides grief services andsupport for family members for at least 12 months.

� Hospice is a benefit under Medicare and is oftencovered by private insurance.

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Put your end-of-life wishes in writing.

For more information, or to locate a hospice in your area, contact Caring Connections:

www.caringinfo.org � caringinfo@nhpco.orgHelpLine 800.658.8898

Multilingual Line 877.658.8896

©2000-2009 National Hospice and Palliative Care Organization.

Item #: 810001 – Communicating End-of-Life Issues

For additional copies of this and other NHPCO products, order online at www.nhpco.org/marketplace or toll-free at

800/646-6460 • 877/779-6472 (fax)

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