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)
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.
*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
Plan Ahead
2
COMMUNICATING
End-of-Life Wishes
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:
3
Decide what you want for your own end-of-life care.
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.
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.
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.
4
COMMUNICATING
End-of-Life Wishes
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:
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
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 stepsfrom 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.
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.
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. SPIKESA 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.