Table 3.

Gold standards framework proactive identification guidance (Principles and materials for the gold standards framework (c) K Thomas, the National GSF Centre 2003-2019. Used with permission from the National GSF Centre in End of Life Care. http://www. goldstandardsframework.org.uk/)

Step 1: The surprise question

“Will you be surprised if the patient dies in the next year, months, weeks, days?”

Step 2: General indicators of increasing dependence or deteriorating health

Generalized deterioration in physical condition, increasing dependence, and needed support for activities of daily living

Multiple unplanned hospital admissions

Advanced CKD with progressive, complicated symptoms

Presence of significant multiple comorbidities

Declining performance status (e.g., Barthel score), unable to do self-care, in bed or chair 50% of day, and increasing dependence in most activities of daily living (Karnofsky performance score ≤50)

Poor response to treatments, decreasing reversibility of disease

Patient’s preference for no further active treatment and focus on quality of life (patients autonomy)

Progressive fall in weight (>10%) over the past 6 months

Unanticipated serious event, e.g., frequent/serious fall, death of loved one

Serum albumin <2.5 g/dl

Step 3: Chronic kidney disease stage 4 or 5 with deterioration with at least two of the indicators below

Patient for whom the surprise question is applicable

Repeated unplanned admissions (>3/year)

Patients with poor tolerance of dialysis with change of modality

Patients choosing the ‘no dialysis’ option (conservative), dialysis withdrawal or not opting for dialysis if transplant has failed

Difficult physical or psychological symptoms that have not responded to specific treatments

Symptomatic renal failure in patients who have chosen not to dialyze nausea and vomiting, anorexia, pruritus, reduced functional status, intractable fluid overload

CKD: Chronic kidney disease