A potentially life-limiting or life-threatening condition and... |
Primary criteria* |
The "surprise question": You would not be surprised if the patient died within 12 months or before adulthood |
Frequent admissions (eg, more than one admission for same condition within several months) |
Admission prompted by difficult-to-control physical or psychological symptoms (eg, moderate to severe symptom intensity for more than 24 to 48 hours) |
Complex care requirements (eg, functional dependency; complex home support for ventilator/antibiotics/feedings) |
Decline in function, feeding intolerance, or unintended decline in weight (eg, failure to thrive) |
Secondary criteria¶ |
Admission from long-term care facility or medical foster homeΔ |
Older patient, cognitively impaired, with acute hip fracture |
Metastatic or locally advanced incurable cancer |
Chronic home oxygen useΔ |
Out-of-hospital cardiac arrest |
Current or past hospice program enrolleeΔ |
Limited social support (eg, family stress, chronic mental illness)Δ |
No history of completing an advance care planning discussion/document |