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? |
- Ascites, recurrent variceal bleeding, encephalopathy, pruritus, dyspnea
- Pain
- Fatigue and sleep disturbance
- Distressing psychological symptoms (depression, anxiety)
- Constitutional symptoms (anorexia, weight loss)
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Social/spiritual assessment |
Are there significant social or spiritual concerns affecting daily life? |
Decision-making |
Is cognitive function adequate for individual 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? |