Patient Information

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Disease Process (Check all that apply)

Cancer (metastatic or recurrentDeclines further dialysisAdvanced COPD (continuous O2, increasingly frequent exacerbations)Advanced renal diseaseAdvanced cardiac disease (CHF, CAD, cardiomyopathy)Advanced liver diseaseStroke with decreased functionAdvanced dementiaFrequent complaints of chest painAscitesAlbumin < 2.5MalnutritionSigns/symptoms of swallow disorderRecurrent infectionsUnhealed pressure ulcers (stage III / IV)Advanced neurological illness (Parkinson's, ALS, MLS)Diabetes, uncontrolled or with complications


Challenging Behaviors (Check all that apply)

Cannot complete any self careCapable of only limited care (unable to comprehend sequence of care)


Functional Status (Check all that apply)

Completely disabled (cannot perform any self care. Totally confined to bed/chair)Capable of only limited self care (confined to bed/chair more than 50% of walking hours)


Other Conditions (Check all that apply)

Need or desire for advance care planning/comfort care only/hospiceRepeat ER visits for same diagnosis in 90 daysMore than one hospital admission in 90 days for same diagnosisProgressive decline despite aggressive treatmentOther uncontrolled symstoms (nausea, insomnia, s.o.b., etc.)Unacceptable level of painrefuses to eatcannot communicate needsUnresolved psychosocial or spiritual issues (family conflict, anxiety, etc.)Difficult for patient to leave home/facility and travel to clinic