PALLIATIVE CARE CONSULT TOOL

Name______Age: ______Date: ______

SCORE
1) Would you be surprised if this patient were alive in one year?
Yes – Score 3 points
No – Score 0
TOTAL SECTION 1 (0 OR 3)
2) Basic Disease Process Score 2 points each
a. / Cancer (metastatic/recurrent)
b. / Advanced COPD (requires home oxygen)
c. / Neurological disease (difficulty swallowing or incontinent)
d. / End stage renal disease (considering stopping dialysis)
e. / Advanced congestive heart failure (one-block DOE)
f. / Greater than 3 hospitalizations or ED visits for incurable disease in past year
g. / Not a candidate for curative surgery
h. / Other terminal or incurable disease causing significant symptoms
TOTAL SECTION 2
3) Uncontrollable Symptoms or Clinical Conditions
Score 2 points each / Score 1 point each / Score 1 point each
a. / Pain / e. / Anxiety / i. / Diarrhea
b. / Dyspnea / f. / Depression / j. / Other ______
c. / Cough / g. / Weight loss
d. / Nausea/Vomiting / h. / Constipation
TOTAL SECTION 3
4) Functional Status
Score using ECOG Performance Status (Eastern Cooperative Oncology Group)
Grade / Scale / Score
0-1 / Fully active, able to carry on all pre-disease activities without restriction or restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. / 0
2 / Ambulatory and capable of most self-care but unable to carry out any work activities. Up and about more than 50% of waking hours. / 1
3 / Capable of only limited self care; confined to bed or chair more than 50% of waking hours or worse. / 2
4
/ Completely disabled. Cannot carry on any self care. Totally Confined to bed or chair. / 3
/ 4
/ TOTAL SECTION 4
5) Psychosocial issues (patient or family) Score 2 points each
/ a. / Need to discuss end of life issues /
/ b. / Need to determine Health Care Proxy /
/ c. / Need for evaluation for possible hospice referral / /
/ d. / Unrealistic goals or expectations /
/ / TOTAL SECTION 5
/ / TOTAL SCORE SECTIONS 1-5
SCORING GUIDELINES:
/ / TOTAL SCORE 8 / Problem-directed; consult if desired /
/ / TOTAL SCORE = 9 - 11 / Consider Advanced Illness Management /
/ / TOTAL SCORE 12 / Strongly consider PC Team or Hospice /

Date of F/U Case Conference:

2013 TER