[link to www.capc.org]

it will be a WHO based schema:

A potentially life-limiting or life-threatening condition and . . .

Primary Criteria

 The ‘‘surprise question’’: You would not be surprised if the patient died within 12 months or before adulthood

 Frequent admissions (e.g., more than one admission for same condition within several months)

 Admission prompted by difficult-to-control physical or psychological symptoms (e.g., moderate-to-severe symptom
intensity for more than 24–48 hours)

 Complex care requirements (e.g., functional dependency; complex home support for ventilator/antibiotics/feedings)

 Decline in function, feeding intolerance, or unintended decline in weight (e.g., failure to thrive)

Secondary Criteria

 Admission from long-term care facility or medical foster home

Elderly patient, cognitively impaired, with acute hip fracture

 Metastatic or locally advanced incurable cancer

 Chronic home oxygen use

 Out-of-hospital cardiac arrest

 Current or past hospice program enrollee

 Limited social support (e.g., family stress, chronic mental illness)

 No history of completing an advance care planning discussion/document



So if Granny breaks a hip, or the family are trailer trash... she's off to the care home in the sky...