1.5 - Identify

This section will introduce you to several tools that can assist you in identifying which patients would benefit from an early conversation.

1. Surprise Question

Would I be surprised if the patient died in the next 6-12 months?
YES doesn't mean that the patient would not benefit from a palliative approach to care. It is important to go on to other indicators.
NO means that this patient may be at high risk for hospitalization or dying in the next year.
It is important to go on to the other indicators and determine priority.


2. Clinical Frailty Scale

The Clinical Frailty Scale is a tool used to assess a patient's instrumental activities of daily living and activities of daily living dependencies, regardless of their diagnosis. Patients who fall into a Moderate Risk or High Risk category should be prioritized for early conversations.

*The Clinical Frailty Scale has not been validated for patients under the age of 65. Please continue to screen patients under 65 using the Surprise Question and the SPICT Tool.

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3. Support and Palliative Care Indicators Tools (SPICT)

The SPICT is a guide to identify patients with one or more advanced condition, deteriorating health, and at risk for dying. It can be used in assessment and care planning purposes. Patients who have two or more general indicators and one or more diagnosis under the clinical indicator section would benefit from having a conversation.

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General Indicators (high risk if 2 or more indicators present)

  • Has there been any unplanned hospitalization?
  • Is the patient in bed/chair more than half a day?
  • Is there increased dependence on others for physical/mental health needs?
  • Does the patient's carer need more help and support?
  • Is there increased weight loss over last 3-6 months or low body mass index?
  • Are there persistent symptoms despite optimal treatment of underlying condition?
  • Is patient/family asking for palliative care; choosing to reduce, stop or not have treatment; or wishes to focus on quality of life?

Clinical indicators (High risk if having 1 or more diagnoses)

Patients may not have all the descriptors below the diagnosis but having the diagnosis is sufficient as a clinical indicator. The more descriptors that apply to their current health state, the higher the priority becomes for having an early conversation.

Cancer
Decrease in functional ability; too frail for cancer treatment; receiving palliative cancer treatment; PPS < 50%.

Dementia/Frailty
Trouble swallowing, eating; needing help with patiental care; difficulty with communicating; may be incontinent; frequent falls/fractures; recurrent aspiration pneumonias. NOTE: A diagnosis of Dementia should automatically trigger the integration of a palliative approach and the initiation of a Goals of Care/Serious Illness Conversation regardless of whether they currently have other indicators such as the Surprise Question or those listed on the SPICT. It is critical to have conversations with the patient about their wishes prior to further cognitive decline.
For more information, view the Dementia Roadmap.

Neurological
Progressive physical/cognitive deterioration; decrease in speech or swallowing difficulties; recurrent aspiration pneumonia; paralysis and/or loss of function post stroke (examples: MS, Parkinson, ALS).

Heart/Vascular Disease
New York Heart Association Class III/IV heart failure; severe coronary artery disease; SOB or pain with minimal exertion; severe inoperable peripheral vascular disease.

Kidney Disease
Stage 4 or 5 chronic renal failure; may have chosen conservative care; may be thinking of stopping dialysis or has stopped dialysis.

Respiratory Disease
Severe chronic lung conditions with SOB with minimal exertion; often on long-term oxygen therapy (examples: COPD, pulmonary fibrosis, interstitial lung disease); has needed ventilator for respiratory failure or ventilator is contraindicated.

Liver Disease
Advanced cirrhosis with complications in the last year (ascites, hepatic encephalopathy, bacterial peritonitis, variceal bleeds); not eligible for transplant.

Other
In general, any patient who is deteriorating and at risk of dying from any other condition or complication that is not reversible ie. substance abuse, mental health concerns.

4. If you use HoNOS or RAI-HC in your daily practice, please review the information below

HoNOS


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The scale is used in community mental health and substance use teams to rate service users on their health or social status. The scale covers a wide range of health and social domains:

  • Psychiatric symptoms
  • Physical health
  • Functioning
  • Relationships
  • Housing
Scoring:
  • 0 = no problem
  • 1 = minor problem requiring no action
  • 2 = mild problem but definitely present
  • 3 = moderately severe problem
  • 4 = severe to very severe problem
  • 9 = not known

HoNOS is done at the start of each episode of care and at the end. Most services using HoNOS also require them done when there is a major change in the patient's status (for instance, an admission to or discharge from hospital) and, for long episodes of care, at every 6 months or so.

HoNOS and IPACE
Using the HoNOS scale with IPACE, mental health teams can integrate their practice of utilizing HoNOS to determine which patient will benefit from having the conversation.

A guide on where to start from a patient caseload
A patient with a score of 3 or 4 in any of the categories of the HoNOS scale would benefit from having the early conversation depending on their mental status. Clinicians should have established interventions to address the problem category. Use clinical judgement regarding patient's capability to have the early conversation. patients who are stable with scores of 0-2 in all categories would most likely have capacity to have the early conversation. It would be a good place to start in terms of finding patients in the beginning to have the conversations. The HoNOS score reflects the patient health/social status for the past 2 weeks. The HoNOS and the early conversation do not necessarily have to be done in the same appointment.

RAI-HC

For IPACE, non-RAI-HC Assessors use the SPICT tool to identify patients who could benefit from early conversation.

RAI-HC Assessors may use outputs from their evidence-based assessment instead of completing an additional tool.

This module reviews how to: 1) identify degree of patient risk based on CHESS/MAPLe intersect research and 2) apply understanding of that risk to IPACE patient identification for early conversation.

Click here if you are a RAI-HC assessor.

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Module 02. Conversation

1.5

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