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 the 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?
- 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.
Clinical frailty scale
The Clinical Frailty Scale was developed by Dr. Kenneth Rockwood at Dalhousie University (2005, 2020) to identify and grade frailty based upon an assessment of their instrumental activities of daily living (iADLs) and ADLs. It can be used to identify those at risk for negative health outcomes (such as risk of mortality or functional decline), and thereby used to prioritize the need for a Goals of Care conversation.
- Scores 1-3 (very fit to managing well): Lower priority for a conversation
- Scores 4-5 (very mild to mild frailty): Moderate priority for a conversation
- Scores 6-8 (moderate to severe frailty): Higher priority for a conversation
- Score 9 (terminally ill, not otherwise frail): Higher priority for a conversation
*The Clinical Frailty Scale has not been validated for use in patients under the age of 65. For those under the age of 65, use the Surprise Question and the SPICT Tool to determine their level of priority for a Goals of Care conversation.
Supportive and palliative care indicator tool (SPICT)
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.
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 a 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 (network access required).
HosNOS tool (adult MHSU teams)
A score of 3 or 4 in any of the categories of the HoNOS scale indicates a 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 the capacity to have this conversation. This is a good place to start in terms of finding patients in the beginning to have conversations.
Dementia roadmap for clinicians
The dementia roadmap uses signposts to help clinicians assess the 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.
Frailty Roadmap for Families
A roadmap which identifies signposts of increasing frailty, including descriptions of various stages