Palliative Care Wales
Welsh Palliative care Indicator Tool

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

Heart Disease
  • 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.
Kidney Disease
  • 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
Respiratory Disease
  • 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.
Liver Disease
  • 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
Neurological Disease
  • 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