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1. Surprise Question (SQ)*
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Would you be surprised if this patient dies within the next 12 months? |
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2.Care need or demand requested
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a) patient or primary caregiver requested exclusive palliative care or comfort measures or requested limitation of therapeutic effort? |
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b) indication by the patient’s physician regarding palliative care need at this moment? |
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3. General clinical indicators of severity and progression
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nutritional markers:
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a) serum albumin < 2.5 mg/dl, unrelated to acute decompensation. |
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b) weight loss > 10% |
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c) perception of severe, progressive, irreversible, nutritional decline and not related to concurrent process |
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functional markers:
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a) severe serious functional dependence; Barthel < 25, ECOG > 2, Karnofsky < 50% |
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b) loss of two or more activities of the daily living, even with adequate therapeutic intervention |
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perception of severe and irreversible functional deterioration
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other markers of frailty and severity in the last six months (at least two):
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a) decubitus ulcer III or IV |
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b) infection with repetitive systemic repercussion (>1) |
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c) acute confusional syndrome |
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d) persistent dysphagia |
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e) falls > 2 |
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presence of emotional stress with progressive and irreversible symptoms.
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additional factors on use of health services:
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a) two or more admittances in emergency or elective services due to chronic illness |
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b) need for full/intense care at home or institution |
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Comorbidities > two pathologies
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4. Clinical indicators of severity and progressive pathology
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neoplasm (one single criterion)
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a) diagnosis of metastatic cancer, contraindication of specific treatment, affects vital organs such as lung, liver, central nervous system |
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b) significant functional impairment PPS < 50% |
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c) poorly controlled persistent symptoms despite optimal treatment |
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chronic obstructive pulmonary disease (two or more criteria):
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a) dyspnea at rest or at minimal exertion between exacerbations |
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b) physical and psychological symptoms of difficult handling |
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c) severe obstruction criteria FEv1 < 30% CVF < 40% |
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d) indication of home oxygen therapy by gasometry criteria |
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e) associated heart failure |
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f) hospitalizations > 3 in 12 months by COPD |
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chronic heart disease (two or more criteria):
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a) Class III or IV CHF, valvar insufficiency and chronic coronary disease |
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b) dyspnea or angina at rest |
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c) physical and psychological symptoms of difficult treatment |
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d) in case of echography: ejection fraction <30% or severe pulmonary hypertension> 60 mmHg |
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e) renal failure: glomerular filtration rate < 30 L/min |
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f) hospital or emergency admission > three in the last year |
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chronic neurological disease (arterial or venous, a single criterion)
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a) subacute phase < three months; vegetative state > three days |
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b) chronic phase > three months; recurrent pneumonia, pyelonephritis > 1, persistent fever > 1 week, grade III or IV pressure ulcer |
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chronic neurological disease: amyotrophic lateral sclerosis and motor neuron diseases, Parkinson’s disease, multiple sclerosis (two or more criteria)
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a) physical deterioration |
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b) complex and difficult to control symptoms |
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c) difficulty with communicating |
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d) progressive dysphagia |
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e) recurrent pneumonia |
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chronic liver disease (a single criterion)
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a) advanced cirrhosis: CHILD C, MELD-Na > 30 HDA with one of the following complications: diuretic resistant ascites, hepatorenal syndrome or portal hypertension with persistent digestive bleeding without response to drug or endoscopic treatment |
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b) stage C or D hepatocellular carcinoma |
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chronic renal failure: glomerular filtration rate < 15 with no indication of substitute treatment or transplantation
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dementia (two or more criteria)
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a) criteria of severity: inability to dress, shower and feed without assistance, urinary and fecal incontinence or inability to communicate meaningfully |
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b) loss of more than two daily activities in the last months, difficulty swallowing, denial to eat |
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c) > three readmissions or emergency service requests in the last 12 months |
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