Identifying patients for supportive, palliative and advance care planning

1) Global assessment

ASK (yourself) - Would it be a surprise if this patient died in the next 6 months? If NO go to section 4

2) General Clinical Indicators

If unsure consider the following: look for two or more general clinical indicators:

• Performance status poor (limited self care; in bed or chair over 50% of the day) or deteriorating.
• Progressive weight loss (>10%) over the past 6 months.
• Two or more unplanned admissions in the past 6 months.
• A new diagnosis of a progressive, life limiting illness.
• Two or more advanced or complex conditions (multi-morbidity).
• Patient is in a nursing care home or NHS continuing care unit; or needs more care at home.

3) Disease Related Indicators

Now look for two or more disease related indicators - If YES go to section 4

• NYHA Class III/IV heart failure, severe valve or coronary artery disease.
• Breathless or chest pain at rest or on minimal exertion.
• Persistent symptoms despite optimal tolerated therapy.
• Systolic blood pressure <100mmHg and /or pulse > 100.
• Renal impairment(eGFR < 30 ml/min).
• Cardiac cachexia.
• >1 acute episodes needing IV therapy in past 6 months.

• Stage 4 or 5 chronic kidney disease (eGFR < 30ml/min).
• Conservative renal management due to multi-morbidity.
• Deteriorating on renal replacement therapy with persistent symptoms and/orincreasing dependency.
• Not starting dialysis following failure of a renal transplant.
• New life limiting condition or kidney failure as a complication of another condition

• Severe airways obstruction (FEV1 < 30%) or restrictive deficit (vital capacity < 60%,transfer factor < 40%).
• Meets criteria for long term oxygen therapy (PaO2 < 7.3 kPa).
• Breathless at rest or on minimal exertion between exacerbations.
• Persistent severe symptoms despite optimal tolerated therapy.
• Symptomatic right heart failure.
• Low body mass index (< 21).
• > 3 emergency admissions for infective exacerbationsor respiratory failure in past year.

• Advanced cirrhosis with one or more complications:
  • intractable ascites
  • hepatic encephalopathy
  • hepatorenal syndrome
  • bacterial peritonitis
  • recurrent variceal bleeds
• Serum albumin < 25g/l and prothrombin time raised or INR prolonged (INR > 2).
• Hepatocellular carcinoma.
• Not fit for liver transplant.

• Performance status deteriorating due to metastatic cancer and/ or co-morbidities.
• Persistent symptoms despite optimal palliative oncology treatment or too frail for treatment

• Progressive deterioration in physical and/or cognitive function despite optimal therapy.
• Symptoms which are complex and difficult to control.
• Progressive speech problems difficulty communicating and/or progressive dysphagia.
• Recurrent aspiration pneumonia; breathless or respiratory failure.

• Unable to dress, walk or eat without assistance; unable to communicate meaningfully.
• Worsening eating problems (dysphagia or dementia related) needing pureed/ soft diet or supplements.
• Recurrent febrile episodes or infections; aspiration pneumonia.
• Urinary and faecal incontinence.

4) Action

If patient's condition fits these criteria:

• Assess patient, family and dependents, including children, for supportive & palliative care needs.
• Review treatment and medication priorities.
• Consider patient for general practice palliative care register.
• Consider advance care plan discussions with patient and family.

Welsh Palliative care Indicator Tool (W-PIT). Adapted from the Supportive and Palliative Care Indicators Toolkit (SPICT) - NHS Lothian