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.
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