Table 1. The NECPAL CCOMS-ICO© tool: general indicators of severity and progression and disease-specific indicators [8, 16].
| The NECPAL tool indicators | |
|---|---|
| Choice, request or need of palliative approach | Has the patient or the main caregiver requested palliative/comfort treatments exclusively or suggests limitation of therapeutic effort? Do healthcare professionals consider that the patient requires PC or palliative treatment at this moment? |
| Functional markers | Serious established functional dependence (Barthel score < 20) Loss of two or more ADLs even though there is adequate therapeutic intervention or clinical perception of functional decline (sustained, intense/severe, progressive, irreversible) not related to concurrent conditions |
| Nutritional markers | Serum albumin <2.5 g/dl, not related to acute episodes of unbalance Weight loss >10% or clinical perception of nutritional decline (sustained, intense/severe, progressive, irreversible) not related to concurrent conditions |
| Emotional | Presence of emotional distress with psychological symptoms (sustained, intense/severe, progressive) not related to acute concurrent conditions |
| Geriatric syndromes in the last 6 months | Persistent pressure ulcers (stages III–IV), recurrent infections (>1), delirium, persistent dysphagia, falls (>2) |
| Comorbidity | Charlson Index [11] |
| Additional factors on use of resources | Two or more urgent (unplanned) hospital (or skilled nursing facilities) admissions due to chronic disease in the last year. Need of complex/intense continuing care, either at an institution or at home |
| Cancer (1 single criterion) | Confirmed diagnosis of metastatic cancer who present low response or contraindication of specific treatment, progressive outbreak during treatment or metastatic affectation of vital organs Significant functional deterioration (PPS ≤ 50%) [17] Persistent, troublesome symptoms, despite optimal treatment of underlying condition(s) |
| Chronic pulmonary disease (≥2 criteria) | Breathlessness at rest or on minimal exertion between exacerbations. Difficult physical or psychological symptoms despite optimal tolerated therapy. FEV1 < 30% or criteria of restricted severe deficit: FVC < 40%/DLCO < 40%. Accomplishment of oxygen therapy at home criteria. Recurrent hospital admissions (>3 admissions in 12 months due to exacerbations) |
| Chronic heart disease (≥2 criteria) |
Heart failure NYHA stage III or IV, severe valve disease or inoperable coronary artery disease. Shortness of breath at rest or minimal exertion. Difficult physical or psychological symptoms despite optimal tolerated therapy. Ejection fraction severely affected (<30%) or severe pulmonary hypertension (>60 mm Hg). Renal failure (GFR < 30 L/minute). Repeated hospital admissions with symptoms of heart failure/ischaemic heart disease (>3 in the last year) |
| Serious chronic liver disease (1 single criterion) | Advanced cirrhosis: stage Child C, MELD-Na Score > 30 or with one or more of the following medical complications: diuretic-resistant ascites, hepatorenal syndrome or upper gastrointestinal bleeding due to portal hypertension with failed response to treatment. Hepatocellular carcinoma: present, in stage C or D (BCLC) |
| Serious chronic renal disease (1 single criterion) | Serious renal failures (GFR < 15) in patients to whom substitutive treatment or transplant is contraindicated |
| Chronic neurological diseases [1]: CVA (1 single criterion) |
During acute and subacute phases (<3 months post stroke): persistent vegetative or minimal conscious state >3 days. During the chronic phase (>3 months post stroke): repeated medical complications (aspiration pneumonia, pyelonephritis, recurrent febrile episodes, pressure ulcers stages 3–4 or dementia with severe criteria post stroke) |
| Chronic neurological diseases [2]: MND, multiple sclerosis and Parkinson (≥2 criteria) | Progressive deterioration in physical and/or cognitive function despite optimal therapy. Complex and difficult symptoms. Speech problems with increasing difficulty communicating. Progressive dysphagia Recurrent aspiration pneumonia, breathless or respiratory failure |
| Dementia (≥2 of the following criteria) | Severity criteria: GDS/FAST 6c or more. Progression criteria: loss of two or more ADLs in the last 6 months, despite adequate therapeutic intervention or difficulty swallowing, or denial to eat, in patients who will not receive enteral or parenteral nutrition. Use of resources criteria: multiple admissions (>3 in 12 months, due to concurrent processes – aspiration pneumonia, pyelonephritis, sepsis, etc. – that cause functional and/or cognitive decline) |
ADL, Activities of daily living; BCLC, Barcelona clinic liver cancer; CVA, Cerebrovascular accident; DLCO, Diffusing capacity of the lung for carbon monoxide; FEV1, Forced expiratory volume in 1 s; FVC, Forced vital capacity; GFR, Glomerular filtration rate; NYHA, New York Heart Association; MND, Motor neuron disease; GDS/FAST, Global deterioration scale/functional assessment; MELD-Na, Model for end-stage liver disease