PALLIATIVE APPROACH INDICATED?
Would I be surprised if this patient died in the next 6-12 months?
Even if your answer is yes, patient can always benefit from advance care planning. See Communication section.
If no, look for one or more of general indicators
General indicators >1
- poor or deteriorating status (limited self-care, in bed or chair over 50% of the day)
- history of multiple hospitalizations in the last 6 months
- need for more care at home (or is already in long term care facility)
- multiple comorbidities causing symptoms or functional decline
- progressive weight loss; remains underweight; low muscle mass.
- persistent symptoms despite optimal treatment of underlying condition(s).
- Patient requests palliative approach
Disease-specific indicators >2
Cancer
- increasing age
- serum calcium >2.8mmol/l
- DVT or PE
- brain mets or CNS involvement in hematological malignancies
- spinal cord compression
- malignant pericardial effusions
- serum albumin <35 mmol/l
too frail for cancer treatment or treatment is for symptom control.
COPD
- body mass index <21
- severe airway obstruction (FEV1<30%) or restrictive deficit (vital capacity <40%)DLCO<40%
- persistent breathlessness at rest or on minimal exertion despite optimal tolerated therapy (exclusive of exacerbation)
- persistent hypoxia needing long-term oxygen therapy.comorbidities of symptomatic heart failure or obstructive sleep apnea
- increased emergency admissions for infective exacerbations and/or respiratory failure
- Needed ventilation for respiratory failure or ventilation is contraindicated.
Dementia
- increasing age
- male gender
- dyspnea
- recurrent febrile episodes or infections, aspiration pneumonia, pressure ulcers
- low oral intake/weight loss/BMI <18.5
Frailty
- age >75
- serum albumin <35
- unable to do self-care (ADL) without help
- progressive weight loss(weight loss >10%)
- low muscle mass
- creatinine >265 mmol/l
- delirium
Heart failure/vascular disease
- NYHA class III/IV heart failure because of valve disease or coronary artery disease not amenable to surgery/angioplasty
- ejection fraction severely affected (<30%) or severe pulmonary hypertension (>60 mm Hg)
- persistent symptoms (breathlessness/chest pain) despite optimal tolerated therapy
- renal impairment (eGFR <30 ml/min)
- cardiac cachexia: progressive loss of lean body mass, reduced muscle strength, anorexia, fatigue
- markers of chronic inflammation/cachexia anemia: hemoglobin <115, uric acid >565, albumin <32
- Severe, inoperable peripheral vascular disease.
HIV/AIDS
- incurable CNS lymphoma
- viral load on maximal therapy >10,000
- poor performance status
- organ failure
- other life-limiting co-morbidities
Liver failure
- age >50
- stage Child C, MELD-Na Score >30
- advanced cirrhosis with one or more complications in the past year: diuretic resistant ascites; hepatic encephalopathy; hepatorenal syndrome; bacterial peritonitis; or recurrent variceal bleeds.
- liver transplant not possible.
Renal failure
- age >80
- stage 4 or 5 chronic kidney disease (eGFR < 30ml/min) with deteriorating health.
- albumin <35
- peripheral vascular disease or vascular dementia
- dementia
- kidney failure complicating other life-limiting conditions or treatments.
- not starting dialysis.
Stroke
Acute
- large volume of brain affected or brain stem
- Increasing age
- Comorbidities
- Function prior to stroke
Chronic
- Degree of disability
- Comorbidities
- Dysphagia causing aspiration
Neurodegenerative diseases
- Age > 75
- Low FVC – respiratory muscle weakness
- Swallowing difficulties &/or poor nutritional status
- Medical complications e.g. aspiration pneumonia, sepsis
- Cognitive impairment
- Rapid spread from onset region to other region — ALS
- Medications less effective — Parkinson’s
If not surprised and patient has general and disease-specific criteria – patient benefits from palliative approach
Talk tip: “We can’t cure your disease, but our goal is to help you live as well as you can for as long as you can.”
Talk tip: ”Although we do not have any further treatments to reverse the disease, there is always something we can do to help you feel better.”