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.
2
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 � [email protected]
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
5
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.
6
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 � [email protected] 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)
1. Doyle D, Hanks GWC, McDonald N. Introduction. In: Doyle D, Hanks GWC, MacDonald D (eds). Oxford
Textbook of Palliative Medicine. Oxford: Oxford University Press; 1993: 3.
2. National Consensus Project for Quality Palliative Care Consortium Organizations. Clinical Practice Guidelines
for Quality Palliative Care. Pittsburgh, PA: National Consensus Project; 2004.
3. World Health Organization. WHO Definition of Palliative Care. Geneva: World Health Organization; 2007.
4. Ferris F, Bruera E, Cherny N, et al. ASCO Special Article. Palliative cancer care a decade later:
accomplishments, the need, next steps—from the American Society of Clinical Oncology. J Clin Oncol.
2009;27(18):3052-3058.
5. Lynn J, Adamson DM. Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old
Age. Santa Monica: Rand; 2003.
6. Pastrana T, Junger S, Ostgathe C, Elsner F, Radbruch L. A matter of definition—key elements identified in a
discourse analysis of definitions of palliative care. Palliat Med. 2008;22(3):222-232.
7. National Quality Forum. A National Framework and Preferred Practices for Palliative and Hospice Care
Quality. A Consensus Report. Available at http://www.qualityforum.org/Projects/n-
r/Palliative_and_Hospice_Care_Framework/Palliative Hospice Care Framework and_Practices.aspx. Last
accessed April 27, 2012.
8. Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients' perspectives. JAMA. 1999;281:163-168.
9. Steinhauser K, Clipp EC, McNeilly M, et al. In search of a good death: observations of patients, families, and
providers.Ann Intern Med. 2000;132:825-832.
10. Elkington H, White P, Addington-Hall J, Higgs R, Pettinari C. The last year of life of COPD: a
qualitative study of symptoms and services. Respir Med. 2004;98(5):439-445.
11. Higginson IJ, Evans CJ. What is the evidence that palliative care teams improve outcomes for
cancer patients and their families? Cancer J. 2010;16(5):423-435.
12. Zimmermann C, Riechelmann R, Krzyzanowska M, Rodin G, Tannock I. Effectiveness of
specialized palliative care. A systematic review. JAMA. 2008;299(14):1698-1709.
13. Epstein R, Street RL Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and
Reducing Suffering. NIH Publication No. 07-6225. Bethesda, MD: National Cancer Institute; 2007.
14. Tattersall M, Butow PN, Clayton JM. Insights from cancer patient communication research.
Hematol Oncol Clin North Am. 2002;16:731-743.
15. de Haes H, Teunissen S. Communication in palliative care: a review of recent literature. Curr
Opin Oncol. 2005;17:345-350.
16. El-Jawahri A, Greer JA, Temel JS. Does palliative care improve outcomes for patients with
incurable illness? A review of the evidence. J Support Oncol. 2011;9(3):87-94.
17. Brumley R, Enquidanos S, Jamison P, et al. Increased satisfaction with care and lower costs:
results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.
18. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care
of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the
American College of Physicians. Ann Intern Med. 2008;148(2):141-146.
19. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved
family members. J Pain Symptom Manage. 2008;36(1):22-28.
20. Abernethy AP, Currow DC, Fazekas BS, Luszcz MA, Wheeler JL, Kuchibhatla M. Specialized
palliative care services are associated with improved short- and long-term caregiver outcomes.
Support Care Cancer. 2008;16(6):585-597.
21. Connor S, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and nonhospice patient
survival among patients who die within a three-year window. J Pain Symptom Manage.
2007;33(3):238-246.
22. Ternel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with non-small-cell lung
cancer. N Engl J Med. 2010;363(8):733-742.
23. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the
integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880-887.
24. Emanuel EJ. Cost savings at the end of life: What do the data show? JAMA. 1996;275:1907-1914.
25. Morrison RS, Dietrich J, Ladwig S, et al. Palliative care consultation teams cut hospital costs for Medicaid
beneficiaries.Health Aff. 2011;30(3):454-463.
26. Coventry PA, Grande GE, Richards DA, Todd CJ. Prediction of appropriate timing of palliative care for older
adults with non-malignant life-threatening disease: a systematic review. Age Aging. 2005;34:218-227.
27. Curtis JR. Palliative and end-of-life care for patients with severe COPD. Eur Respir J. 2008;32(3):796-803.
28. Institute for Clinical Systems Improvement. Health Care Guideline: Palliative Care. 3rd ed. Available at
http://www.icsi.org/guidelines_and_more/gl_os_prot/other_health_care_conditions/palliative_care/palliative
_care_11875.html. Last accessed May 16, 2012.
29. Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating
prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and
their caregivers. Med J Aust. 2007;188(12 Suppl):S77, S79, S83-S108.
30. Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the
hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med.
2011;14(1):17-23.
31. Swetz KM, Freeman MR, AbouEzzeddine OF, et al. Palliative medicine consultation for
preparedness planning in patients receiving left ventricular assist devices as destination therapy.
Mayo Clin Proc. 2011;86(6):493-500.
32. Renal Physicians Association. Shared Decision-Making in the Appropriate Initiation and Withdrawal from
Dialysis. Clinical Practice Guideline. 2nd ed. Rockville, MD: Renal Physicians Association; 2010.
33. Center to Advance Palliative Care. 2011 Public Opinion Research on Palliative Care: A Report
Based on Research by Public Opinion Strategies. New York, NY: Center to Advance Palliative
Care; 2011.
34. Cambia Health Foundation. Living Well at the End of Life: A National Conversation: Results of
2011 Poll. Available at http://www.cambiahealthfoundation.org/nationalJournal.html. Last
accessed May 16, 2012.
35. Shanawani H, Wenrich MD, Tonelli MR, Curtis JR. Meeting physicians' responsibilities in
providing end-of-life care. Chest. 2008;133(3):775-786.
36. Quill TE. Initiating end-of-life discussions with seriously ill patients: addressing the "elephant in
the room." JAMA. 2000;284(19):2502-2507.
37. Parker SM, Clayton JM, Hancock K, et al. A systematic review of prognostic/end-of-life
communication with adults in the advanced stages of a life-limiting illness: patient/caregiver
preferences for the content, style, and timing of information n.J Pain Symptom Manage.
2007;34(1):81-93.
38. Werb R. Palliative care in the treatment of end-stage renal failure. Prim Care Clin Office Pract.
2011;38:299-309.
39. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—A six-step protocol for
delivering bad news: application to the patient with cancer. Oncologist. 2000;5:302-311.
40. Buckman R. Communication skills in palliative care: a practical guide. Neurol Clin.
2001;19(4):989-1004.
41. Torke AM, Siegler M, Abalos A, Moloney RM, Alexander GC. Physicians' experience with
surrogate decision making for hospitalized adults. J Gen Intern Med. 2009;24(9):1023-1028.
42. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making
before death. N Engl J Med. 2010;362(13):1211-1218.
43. Nicholas LN, Langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between
advance directives and end-of-life Medicare expenditures. JAMA. 2011;306(13):1447-1453.
44. Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative care at the end of life: a
systematic review. Ann Intern Med. 2008;148(2):147-159.
45. Mahler DA, Selecky PA, Harrod CG, et al. American College of Chest Physicians consensus
statement on the management of dyspnea in patients with advanced lung or heart disease.
Chest. 2010;137(3):674-691.
46. Douglas C, Murtagh FE, Chambers EJ, Howse M, Ellershaw J. Symptom management for the
adult patient dying with advanced chronic kidney disease: a review of the literature and
development of evidence-based guidelines by a United Kingdom Expert Consensus Group.
Palliat Med. 2009;23(2):103-110.
47. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality
Palliative Care. 2nd ed. Pittsburgh, PA: National Consensus Project for Quality Palliative Care;
2009. Summary retrieved from National Guideline Clearinghouse at
http://www.guideline.gov/content.aspx?id=14423. Last accessed May 24, 2012.
48. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care
of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the
American College of Physicians. Ann Intern Med. 2008;148(2):141-146. Summary retrieved from
National Guideline Clearinghouse at http://www.guideline.gov/content.aspx?id=12149. Last
accessed May 24, 2012.
49. Net CE.com. Resource number 9738: Palliative care and pain management at the end of life.
Alexander, Lori.
50. Daniel Simons and Christopher Chabris, © 1999. VISCOG productions. www.viscog.com.
Top Related