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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______

Over
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 Full Normal Full
No evidence of Disease
90 Full Normal Activity Full Normal Full
Some evidence of Disease
80 Full Normal Activity with Effort Full Normal or Full
Some evidence of Disease Reduced
70 Reduced Unable Normal Job/Work Full Normal or Full
Some evidence of Disease Reduced
60 Reduced Unable Hobby/House Work Occasional Assistance Normal or Full or Confusion
Significant Disease Required Reduced
50 Mainly Sit Unable to Do Any Work Considerable Normal or Full or Confusion
and/or Lie Extensive Disease Assistance Required Reduced
40 Totally Bed Unable to Do Any Work Mainly Assistance Normal or Full or Drowsy or
Bound Extensive Disease Reduced Confusion
30 Totally Bed Unable to Do Any Work Total Care Reduced Full or Drowsy or
Bound Extensive Disease Confusion
20 Totally Bed Unable to Do Any Work Total Care Minimal Sips Full or Drowsy or
Bound Extensive Disease Confusion
10 Totally Bed Unable to Do Any Work Total Care Mouth Care Drowsy or Coma
Bound Extensive Disease Only
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_______

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


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

At Time of Hospital Admission

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
Primary
Admission for difficult physical or psychologic symptoms
criteria*
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)

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
Secondary
Chronic use of home oxygen use
criteria
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

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
Primary
Stay in intensive care unit of 7 days or more
criteria*
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

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
Secondary
Patient/family/surrogate request for palliative care/hospice services
criteria
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.
COMMUNICATING
End-of-Life Wishes
Hospice
Its 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

Communicating End-of-Life Wishes

Experts agree the time to discuss your views about


end-of-life care, and to learn about the end-of-life
care choices available, is before a life-limiting illness
occurs or a crisis happens. By preparing in advance,
you can help reduce the doubt or anxiety related to
making decisions for your family member when
they cannot speak for themselves.

Plan Ahead

The time to communicate end-of-life care wishes


is now when you and your loved ones are still able
to discuss your choices. Review the steps below and
share them with your friends and family to
communicate end-of-life wishes.

2
COMMUNICATING
End-of-Life Wishes

The following are simple steps to ensure that end-of-life care


wishes are followed:

Draw up a living will of written instructions to


communicate care and treatment wishes and
preferences in the event you cannot speak for yourself.
Have a durable power of attorney in place that allows
a person of your choosing to make medical decisions
for 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 and
make 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 care
wishes known, however it is just as important to have personal
conversations with family and loved ones about these issues.

Discuss Your Wishes Early

Discuss your end-of-life care wishes with family and loved ones
now before a crisis happens. The following can be used as
opportunities for having this conversation:

Around significant life events, such as marriage, birth


of 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 member
move 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 facing
illness or an end-of-life situation

3
Decide what you want for your own end-of-life care.

Whenever possible, include your children in these conversa-


tions, not just your parents, spouse or partner. It is never too
early to start thinking about these issues. Have regular
discussions about your views on end-of-life care, since they may
change over time. And dont forget to discuss your end-of-life
care wishes with your doctor. Here are a few helpful pointers
to keep in mind as you plan for having this conversation:

1. Do Your Homework
Before beginning the discussion, learn about end-of- life care
services available in your community. Become familiar with
what each option offers so you can decide which ones meet
your loved one or your own, end-of-life care needs and wants.

2. Select an Appropriate Setting


Plan for the conversation. Find a quiet, comfortable place
that is free from distractions to hold a one-on-one discussion
or family meeting. Usually, a private setting is best.

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

Some ways of asking permission are:

Id like to talk about the best way someone might care for you
if you got really sick. Is that okay?

If you ever got sick, I would be afraid of not knowing the kind
of care you would like. Could we talk about this now? Id feel
better if we did.

I want to share my wishes about how Id like to be cared for in


the event I was sick or injured; can we do that now?

Another method of beginning the conversation is to share


an article, magazine, or story about the topic with your
loved one. Even watching a TV show or movie on the
topic together can encourage the conversation. If you
think your loved one would be more comfortable with
someone else, you can suggest they talk to another family
member, a friend or faith leader.

4
COMMUNICATING
End-of-Life Wishes

4. Begin the Conversation


Keep in mind that you started this conversation because
you care about your loved one wellbeing especially
during difficult times. Allow your loved one to set the pace.
Nodding your head in agreement, holding your loved one
hand, and reaching out to offer a hug or comforting touch
are ways that you can show your love and concern.

Understand that it is normal for your loved ones to avoid


this discussion. Dont be surprised or upset; instead, plan
to 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 a
homelike setting?
Do you think its important to have medical attention and
pain control to fit your needs?
Is it important for you and your family to have
emotional 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 Listener
Keep in mind that this is a conversation, not a debate.
Sometimes just having someone to talk to is a big help. Be
sure to make an effort to hear and understand what the
person is saying. These moments, although difficult, are
important 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 with
you is important.
Show empathy and respect by addressing these wants
and needs in a truthful and open way.
Acknowledge your loved one right to make life
choices even if you do not agree with them.

5
Put your end-of-life wishes in writing.

6. Call Hospice
If you or those you love are struggling to cope with
a life-limiting illness, help is available through hospice.
Hospice programs provide quality care focusing on comfort
and 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 offer


expert medical care, pain management, and
emotional and spiritual support to meet the needs and
wishes of the person who is ill.
Emotional support is also provided to the patients
loved ones.
Hospice focuses on aggressively treating pain or
symptoms to make the person as comfortable as
possible. Care is usually provided in the persons 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 of
payment.
Members of the hospice staff make regular visits to
assess the person who is ill and provide extra care or
other services. Hospice staff is on-call 24 hours a day,
seven days a week.
The hospice team which includes the person who
is ill, family/ carnegies, doctors, nurses, social workers,
spiritual carnegies, counselors, home health aides, and
trained volunteers develops a care plan that meets
each persons individual needs for care and support.
The care plan describes the services needed such as
nursing care, personal care (dressing, bathing, etc.),
emotional support, and doctor visits. It also identifies the
medical equipment, tests, procedures, medication and
treatments necessary to provide high-quality comfort care.
After death, hospice provides grief services and
support for family members for at least 12 months.
Hospice is a benefit under Medicare and is often
covered by private insurance.

6
For more information, or to locate a hospice
in your area, contact Caring Connections:
www.caringinfo.org caringinfo@nhpco.org
HelpLine 800.658.8898
Multilingual Line 877.658.8896

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)

2000-2009 National Hospice and Palliative Care Organization.


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