Is 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

  • a poor or deteriorating status (limited self-care, in bed or chair over 50% of the day)
  • a history of multiple hospitalizations in the last 6 months
  • a need for more care at home (or is already in a residential facility)
  • multiple comorbidities causing symptoms or functional decline
  • Patient requests palliative approach

Disease-specific indicators >2


  • 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


  • body mass index <21
  • severe airway obstruction (FEV1<30%) or restrictive deficit (vital capacity <60%)
  • persistent breathlessness at rest or on minimal exertion despite optimal tolerated therapy (exclusive of exacerbation)
  • six minute walk distance of <100 meters
  • comorbidities of symptomatic heart failure or obstructive sleep apnea
  • depression, anxiety, living alone
  • increased emergency admissions for infective exacerbations and/or respiratory failure


  • increasing age
  • male gender
  • dyspnea
  • recurrent lung aspiration
  • pressure ulcers
  • low oral intake/weight loss/BMI <18.5


  • age >75
  • serum albumin <35
  • unable to do self-care (ADL) without assistance
  • malnutrition (weight loss >10%)
  • heart failure
  • creatinine >265 mmol/l
  • delirium

Heart failure

  • NYHA class III/IV heart failure due to valve disease or coronary artery disease not amenable to surgery/angioplasty
  • 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
  • two or more episodes needing intravenous (furosemide and/or
    inotropes) therapy in last 6 months


  • age >65 years
  • CNS lymphoma
  • viral load on HAART >10,000
  • poor performance status
  • other life-limiting co-morbidities

Liver failure

  • age >50
  • serum bilirubin >237 that does not respond well to therapy
  • eGFR <40ml/min
  • ascites present
  • encephalopathy present

Renal failure on hemodialysis

  • age >80
  • albumin <35
  • peripheral vascular disease
  • dementia
  • other comorbidities such as heart or liver disease, stroke, diabetes with end-stage organ damage



  • large volume of brain affected
  • Increasing age
  • Comorbidities
  • Function prior to stroke


  • Degree of disability
  • Comorbidities
  • Dysphagia causing aspiration

Other neurodegenerative diseases

  • Age > 75
  • Low FVC – respiratory muscle weakness
  • Swallowing difficulties &/or poor nutritional status
  • Medical complications e.g. aspiration pneumonia or 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.”

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