Patient ID & Demographics

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Palliative Care Trigger Tool – Adult Critical Care

***To be used only on Surgical Critical Care Patients***

Please use this trigger tool to identify patients with Advanced (End-Stage) Disease who may benefit from an early Palliative Care Consult or Hospice Referral.

Does this patient have an Advanced Directive?

ÿ  Yes

ÿ  No

Does this patient meet any of the following criteria? (Please check all that apply):

ÿ  You would not be surprised if the patient died within 12 months

ÿ  Metastatic cancer

ÿ  Oxygen dependent

ÿ  Advanced cardiac disease (CHF, CAD, LVEF 25%)

ÿ  Lack of clarity of goals/plan of care

ÿ  Frequent admissions or admission from long-term care facility

ÿ  Admission prompted by difficult-to-control physical or psychological symptoms

ÿ  Complex care requirements or decline in functional status/ADL’s (functional dependency, complex home support for ventilator/antibiotics/feedings/unintended decline in weight)

ÿ  Elderly patient, cognitively impaired, with acute hip fracture

ÿ  Out-of-hospital cardiac arrest

ÿ  Code status of DNR

ÿ  Current or past hospice program enrollee

ÿ  Limited social support (family stress / chronic mental illness)

ÿ  Intracranial Hemorrhage (Intraparenchymal hemorrhage / hemorrhage with midline shift)

ÿ  Patient is a candidate for: tracheostomy / feeding tube / LVAD / ICD placement

ÿ  Initiation of renal replacement therapy

ÿ  Ethics concerns and/or disagreements among the patient, staff and family concerning: major medical treatment decisions and resuscitation preference

ÿ  Patient/family emotional, spiritual or relational distress

If you feel the patient would benefit from a palliative care consult, please order the consult.

Did you request a Palliative Care Consult?

  Yes and discussed with patient/family

  No, explain:

This form is to be placed in the patient’s hardcopy chart as top page in the Progress Notes section and should stay with the patient chart until discharge.

Unit Secretary, remove this form when disassembling the patient chart after discharge. Please mail copies to the Quality Department, interoffice mail MC 087. If questions, call the Quality Department at 391-1493.

NOTE: This form is NOT to become part of the patient’s permanent medical record. It is intended for data collection purposes only.

Created 12/30/13, Revision 6: 4/1/14