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RPACE - Identification

A palliative approach to care can begin at the time of diagnosis of a serious illness (or at any stage of illness) if this approach is aligned with the person's wishes. All interdisciplinary team members can use the following identification tools to identify which of their patients are at highest risk for health deterioration. Clinicians can then prioritize which patients are in urgent need of a conversation to clearly understand their patient's wishes and priorities for care. It is important to recognize the signs of illness progression and decline throughout the illness journey, not only when the patient reaches the end of life stage.

General identification assessment tools for indicating health deterioration

Question: Would it surprise me if this person died in the next 6-12 months?

Your Answer:

If YES, I would be surprised. 

This does not mean that the person would not benefit from a palliative approach to care. It is important to use additional tools for a comprehensive assessment.

If NO, I would not be surprised.

This means that this patient may be at high risk for hospitalization or dying in the next year, therefore they require an urgent conversation.


Assess the person's frailty according to the scale to determine if they are at low, moderate or high risk for health deterioration.

With every health crisis, consider how their frailty has been affected (think about rate of frailty progression, rehab potential, new baseline). Rehab clinicians, with their focus on function and mobility, may be especially helpful in assessing the stages of frailty.

Download the Clinical Frailty Scale PDF: 


This tool lists general and clinical indicators for health deterioration due to one or more health conditions. Check off the indicators that apply to the patient you are assessing.

Assess for general indicators

 Unplanned hospitalization (including Emergency visits).

 Poor performance status with limited reversibility. In bed/ chair for more than 50% of the day.

 Dependence on others for care.

 Caregiver requiring more help and support.

 Weight loss, remains underweight, low body mass index.

 Person/ family wanting to focus on palliative care, quality of life, or stop  treatments.

Assess for these diagnoses (and look for clinical indicators within)


 Dementia/ Frailty

 Neurological Disease

 Heart/ Vascular Disease

 Respiratory Disease

 Kidney Disease

 Liver Disease

 Other diseases

Tally your checks: If the individual  has < 3 indicator they are low risk, 4-6 indicators means they are moderate risk, and > 6 indicators means they are high risk for health deterioration.

If you have a caseload, you can review individuals' risk by tallying up identification indicators using the My client Identification Worksheet.

Download the Supportive Palliative Care Indicators Tool PDF:



Supplementary Identification Assessment Tools

RAI-HC Assessors may use outputs from their evidence-based assessment to assess risk and prioritize clients at high risk of health deterioration. Please review the online course (coming soon) for high-risk indicators and evidence supporting this.

If an individual has a CPS score of 0-2, this is good opportunity to ensure goals of care conversations are started with the individual. When the CPS score is 3+, this indicates there is difficulty in daily decision making. Consider including the Substitute Decision Maker in the conversation at that time.

Please review the Care Planning Resources on the RAI-HC Clinical Resource site (internal link).


Score of 3 or 4 in any of the categories of the HoNOS scale indicate high risk of deterioration. Clinicians should have established interventions to address the problem category.

Scores of 0-2 in all categories would most likely have capacity to have this conversation. This is a good place to start in terms of finding patients in the beginning to have the conversations.


The dementia roadmap uses signposts to helps clinicians assess stages of dementia. Individuals in early-stage dementia are at risk of advancing cognitive decline and therefore at high risk of deterioration. Prioritize conversations with these individuals to identify their wishes and priorities before it is too late to do so. 

Download the Dementia Roadmap for Clinicians PDF:

SOURCE: RPACE - Identification ( )
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