NUR3500 Chap.4 Identifying Who Needs Palliative Care
Identifying Who Needs Palliative Care
The problem this chapter solves
The hardest practical problem in palliative care is not what to do; it is noticing in time. Identification tools exist because clinicians consistently over-estimate how long people have, and because the diagnosis on the front of the notes is a poor guide to who is deteriorating.
The screening tool used here therefore starts with signs that are deliberately disease independent.
General indicators of deterioration
The tool asks whether there have been urgent or emergency admissions; whether functional ability is poor or falling with little prospect of reversal, for instance more than half the day spent in bed or a chair; whether the person depends more on others and whether the carer now needs more help; whether weight is falling or muscle mass is low; whether symptoms persist despite optimal treatment; and whether the person or family has asked for palliative care, chosen to reduce, stop or decline treatment, or said they want the focus to be quality of life.
Two or more of these should prompt a review.
Beside them sits a deliberately blunt prompt: would you be surprised if this person died in the next six to twelve months? It is not a prognostic instrument and it is not accurate for an individual.
Its function is to interrupt automatic thinking, and a clinician who answers no has already conceded that the trajectory has changed.
Condition specific signals
After the general indicators the tool lists what advanced disease looks like in each condition, and these rows are the ones most often tested directly because each is an observable fact.
In cancer, function falling because of the cancer itself, or being too frail for treatment. In dementia and frailty, being unable to dress, walk or eat unaided, eating and drinking less with swallowing difficulty, incontinence, little speech, repeated falls and recurrent infections. In heart disease, chest pain or breathlessness on minimal exertion or even at rest.
In respiratory disease, breathlessness at rest even between flare-ups, and a low blood oxygen level that persists.
In kidney disease, chronic kidney disease at stage four or beyond with health worsening, or dialysis withdrawn or declined from the outset.
Identification is only half the tool
The same instrument then directs a review: reconsider treatments and reduce unnecessary medication, decide jointly with the person, review the whole range of needs rather than symptoms alone, ask for specialist advice where problems are hard to control, agree a current and future care plan including who will decide, and record and share it.
A student who can list the indicators but not the actions has learned half the page.
Frailty and symptom burden are different questions
A clinical frailty scale running from very fit to terminally ill grades overall fitness on clinical judgement and is used nationally to decide who should be offered fuller assessment.
A brief questionnaire on fatigue, stairs, walking, number of illnesses and weight loss gives a faster screen. A self reported symptom scale covering wellbeing together with pain, tiredness, drowsiness, nausea, appetite, breathlessness, depression and anxiety measures suffering rather than reserve.
A severely frail person may be comfortable and a robust one may be in severe pain, which is why the two scores are never substitutes.
What this chapter covers
- 01
General indicators of deteriorating health
- 02
The surprise question and its purpose
- 03
Condition specific signals of advanced disease
- 04
The review the tool then directs
- 05
Frailty grading compared with symptom scoring
Does this patient meet the threshold for review?
- 2Count the general indicators present and state the threshold.
- 1Name the condition specific signal and why it matters here.
- 3Set out the review actions the tool directs.
Key terms
- General indicator
- A sign of deteriorating health that applies regardless of diagnosis, such as repeated emergency admissions or falling function.
- Surprise question
- The prompt asking whether you would be surprised if this person died within six to twelve months, used to interrupt automatic thinking.
- Clinical frailty scale
- A judgement based grading of overall fitness from very fit through to terminally ill, used for risk stratification.
- Symptom assessment scale
- A self reported instrument scoring wellbeing alongside physical and emotional symptoms, used to track change over time.
- Functional ability
- What a person can still do for themselves, measured by how much of the day is spent in bed or a chair and how much help is needed.
- Needs based referral
- Referral triggered by unmet need rather than by an estimated prognosis or a particular diagnosis.
Identifying Who Needs Palliative Care FAQ
How many indicators are needed before I should raise a review?
Two or more general indicators of deteriorating health is the working threshold, and the condition specific rows strengthen the case rather than replacing it. The point of a threshold is that it removes the need to make a prognosis estimate before acting.
Is the surprise question a way of predicting how long someone has?
No. It is inaccurate for any individual and it is not designed as a prognostic instrument. It works as a prompt: a clinician who answers no has conceded that the trajectory has changed, and the next step is a review of symptoms, medication and planning.
Why score frailty and symptoms separately?
They answer different questions. Frailty describes reserve and predicts risk, while a symptom score describes what the person is suffering now. A severely frail patient may be comfortable and a robust patient may be in severe pain, so one score cannot stand in for the other.
Exam move
Write the general indicators from memory and check the count, then add one condition specific row for each of cancer, dementia, heart, lung and kidney disease. Finish by listing the review actions, because those are the half most often forgotten.
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