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. Author manuscript; available in PMC: 2017 Jan 1.
Published in final edited form as: Trends Cardiovasc Med. 2015 Apr 3;26(1):36–43. doi: 10.1016/j.tcm.2015.03.018
• Annual visit • Disease worsening/ progression
• Repeated or severe hospitalization(s) • Considering major procedures or interventions
• Change in functional or health status • Change in social support system, death of a spouse
• Change in living situation (independent to assisted or long-term care facility) • Clinician response of “no” to “Would you be surprised if this patient died in the next year?”