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
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
COPD
- 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
Dementia
- increasing age
- male gender
- dyspnea
- recurrent lung aspiration
- pressure ulcers
- low oral intake/weight loss/BMI <18.5
Frailty
- 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
HIV/AIDS
- 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
Stroke
Acute
- large volume of brain affected
- Increasing age
- Comorbidities
- Function prior to stroke
Chronic
- 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.”