| Understanding of illness/prognosis and treatment options |
| Does the patient/family/surrogate understand the current illness, their prognosis for quantity and quality of life, expected disease trajectory/uncertainty about disease trajectory, and treatment options? |
| Symptom management |
| Does the patient have uncontrolled/distressing symptoms? In particular, does the patient have any of the following? |
- Pulmonary symptoms (cough, dyspnea) with daily activities
- Pain
- Fatigue and sleep disturbance
- Distressing psychological symptoms (depression and anxiety)
- Constitutional symptoms (anorexia and weight loss)
|
| Social/spiritual assessment |
| Are there significant social or spiritual concerns affecting daily life? |
| Decision making |
| Is the patient comfortable making health care decisions? Or, does the patient rely on family members, friends, or health care professionals to make decisions? |
| Has the patient identified a surrogate decision-maker and talked with this person about their goals and values? |
| Would the patient/family/surrogate like help with treatment decision-making? |
| Identification of patient-centered goals of care |
| What are the goals for care, as identified by the patient/family/surrogate? |
| Are treatment options matched to informed patient-centered goals? |
| Has the patient participated in an advance care planning process? |
| Has the patient completed an advance care planning document? |
| Coping with life-threatening illness |
| How is the patient coping with their illness? |
| How are the family/family caregivers coping with the illness? |
| Coordination of care |
| Are there barriers to safe and sustainable transitions from one setting to another (eg, transportation to appointments)? |
| Are systems in place to enable good communication between multiple providers? |
