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Palliative Care Screening Quiz

Basic Disease Process

Cancer: metastatic/recurrent | 2 points

Advanced COPD | 2 points

Stroke with decreased function of 50% or > | 2 points

End stage renal or liver disease | 2 points

Advanced cardiac disease; CHF, CAD, cardiomyopathy | 2 points

Other life-limiting illness (ex: ALS, dementia) | 2 points

Functional Status (Using ECOG Performance Status)

Fully active, able to carry on all activities without restriction. | 0 points

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature i.e., light housekeeping. | 0 points

Ambulatory and capable of self-care but not work activities. Up more than 50% of waking hours. | 1 point

Capable of limited self-care; confined to bed or chair more than 50% of waking hours. | 2 points

Completely disabled. Not able to do self-care. Totally confined to bed or chair. | 3 points

The Patient

Is not a candidate for curative therapy. | 1 point

Has a life-limiting illness and has chosen not to have life-prolonging therapy. | 1 point

Has unacceptable pain > 24 hours. | 1 point

Has uncontrolled symptoms (i.e., nausea, vomiting). | 1 point

Has uncontrolled psychosocial or spiritual issues. | 1 point

Has frequent visits to the ER (> 1 x month for same diagnosis). | 1 point

Has more than one hospital admission for the same diagnosis in last 30 days. | 1 point

Has prolonged length of stay without evidence of progress. | 1 point

Is in an ICU with documented poor or futile prognosis. | 1 point

Has family support needs or communication challenges. | 1 point

Total Score

2 points = No intervention needed.
3 points = Observation only.
4 points or > = Consider palliative care consult.

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Pure Healthcare

Palliative Care
Toll-free 833.600.PURE
or 833.600.7873

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Home Health Care
833.444.4177

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