3 Escalas en Cuidados Paliativos

Main ideas and lessons

• The video explains how to assess functional status and palliative care needs using several clinical scales, and how these assessments help determine the level of palliative care a patient may require.
• It distinguishes:
  • Functional-status scales (mainly about mobility/ability to perform activities; often used in oncology and general clinical evaluation)
  • From palliative-needs identification tools (multidimensional tools designed to detect patients who may benefit from earlier/ongoing palliative care)
  • Then from tools used to estimate complexity, helping decide whether care should be primary, secondary, or specialized.

Scales for palliative care (functional status)

1) Karnofsky Performance/Functional Status Scale (often “Karnovsky” in subtitles)

Purpose

• Used frequently in primary care.
• Measures capacity/function, reflecting:
  • discomfort level
  • evidence of disease
  • ability to work/perform normal activities
  • need for care

Score meaning (percent capacity)

• 100%: No discomfort; no evidence of disease; able to perform normal activities and work; no special care needed.
• 100% to 80%: Most normal activities possible, with some limitations/discomfort and some disease evidence.
• 70% to 50%:
  • Unable to work
  • Can live at home
  • Can meet most personal needs
  • Requires a variable amount of assistance
• Below 40%:
  • Unable to care for self
  • Requires institutional/hospital care
  • Disease may be rapidly progressing

Subtitles may compress ranges; the key idea is that lower percentages indicate greater dependency and higher care needs.

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2) ECOG / PS (Performance Status Scale; “Performance Scale”)

Purpose

• Used to assess functional status, especially in oncology (also relevant more broadly in palliative care).
• Subtitles clarify naming to reduce confusion:
  • ECOG/PS: Performance Status
  • PPS: Palliative Performance Scale (a different tool discussed next)

Staging (as described)

• Scores are commonly represented as levels 0–4 in ECOG systems, with 5 for death (as described).

Stage 0

• Fully active; all activities possible without restriction.

Stage 1

• Restricted only in very strenuous physical activities; still able to walk and do light work (e.g., work from home/office).

Stage 2

• Able to walk and do self-care, but cannot do any work.

Stage 2 vs 3 distinction (as described)

• Stage 2: ~50% of waking hours standing
• Stage 3: >50% of waking hours sitting/lying in bed

Stage 4

• Totally incapacitated; unable to perform self-care; confined to chair.

Stage 5

• Death (as defined in the subtitles).

Clinical implication mentioned

• ECOG 1–2 often corresponds to more oncology treatment options than worse functional status (e.g., stage 4).

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3) PPS (Palliative Performance Scale) — palliative-focused and blended

Purpose

• A palliative-care-oriented scale that blends features from functional scales.
• Described as less known than Karnofsky/ECOG and designed for palliative contexts.

Key assumption

• Framed for patients with advanced illness (unlike Karnofsky/ECOG, which are used without necessarily assuming advanced disease).

Scores described

• 100% PPS: Normal work activity; no evidence of disease.
• 100%–80%: Can perform activities with effort; some disease evidence.
• 90% or 80%: Total self-care; intake normal; at 80% slight intake reduction possible; consciousness total.
• 70%:
  • Reduced mobility
  • Unable to do normal work
  • Disease significant in daily life
  • Self-care may still be total
  • Intake normal or reduced
  • Consciousness total
• 60%:
  • No longer able to do hobbies/housework
  • Disease significant
  • Occasional assistance needed for self-care
  • Intake normal or reduced
  • Consciousness fully conscious or confused
• 50%:
  • Mainly sitting or lying
  • Similar to high ECOG restriction (unable to perform activities/work)
  • Extensive disease
  • Regular assistance for self-care
  • Consciousness normal, reduced, or fully conscious
• 40%:
  • Mainly bedridden
  • Unable to perform most activities
  • Extensive disease
  • Assistance required for almost everything
  • Intake normal/reduced; often more confusion
• 10%:
  • Bedridden
  • Permanent care
  • Intake reduced to oral feeding
  • Confused; closer to end of life

Overall lesson

• PPS helps clinicians estimate functional decline over time, supporting assessment of likely needs and urgency for palliative interventions.

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NECPAL (multidimensional early identification of palliative needs)

What it is (as described)

Purpose

• Identifies patients with relatively limited life expectancy.
• Enables progressive incorporation of a palliative approach into routine chronic illness care as illness advances.
• Mentioned as appearing in technical guidance associated with the “Cuos Peliaos” program (subtitle text may include minor errors in the exact name).

Origins and versioning

• Developed by an “Observatory” within a collaborating center of a public program (Catalan Institute of Oncology mentioned).
• Versions described:
  • Original: 13 items
  • Chilean version: 10 items
• Administered by primary care physician/nurse using medical records—without requiring patient/family participation.

Surprise Question (first screening item)

• Asked of the professional:
  • “Would it surprise you if the patient you are evaluating were to die within the next 12 months?”
• If not surprised → marked positive (as phrased in subtitles)
• If surprised → marked negative
• Used as a first step to determine whether the patient may have palliative needs and could be eligible for admission.

Other items (record-based clinical criteria)

• Review of medical record criteria, including examples of positive criteria such as:
  • Functional loss
  • Sustained, severe, progressive functional impairment
  • Regression or >30% loss in body composition within 6 months
  • Sustained, severe, progressive, irreversible nutritional impairment

  • 10% weight loss in 6 months

  • Morbidity: ≥2 chronic diseases affecting the main disease
  • Resource use: ≥2 urgent hospital admissions in the last year
  • Need for complex, intensive, continuous care
  • Advanced disease severity/progression in organ-system categories:
    • oncological, pulmonary, cardiac, hepatic, renal, neurological
    • dementia mentioned as an example

Staging / versions for Chile

• Chile-validated standard version described as 3.0
• Version 4.0 mentioned for needed adjustments in admission prioritization.
• Used to determine:
  • whether the person has palliative needs
  • and the likely complexity level to guide care pathways

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Complexity assessment: determining the care level

Goal

• Determine the complexity of palliative need to decide whether appropriate care is:
  • Primary
  • Secondary
  • or both

Domains

• Multiple domains contribute, including:
  • patient-dependent
  • family/environment-dependent
  • healthcare organization/team/resource-dependent
  • (subtitles reference multiple domain labels; the main point is that complexity can originate from different sources)

Complexity categories (as described)

• If any domain item is classified as AC (high complexity) → patient considered highly complex.
• If none are high complexity but some are complex → patient considered complex.
• Subtitles also suggest some profiles may automatically indicate higher complexity, such as:
  • child/adolescent
  • healthcare professional
  • complex socio-familial role (e.g., mother with small children)
  • prior physical/mental/sensory disability
  • recent/active addiction problems or mental illness

Examples of “highly complex” clinical situations

• Difficult-to-control or refractory symptoms
• Urgent situations in terminal cancer
• Difficult “last day” clinical situations

• Tumor-related clinical situations hard to manage Examples listed:

• Acute decompensation in organ failure in terminal cancer

• Severe cognitive disorder
• Abrupt changes in functional autonomy
• Severe constitutional syndrome
• Difficult management due to repeated therapeutic non-compliance
• Psycho-emotional situations such as:
  • suicide risk
  • requests to hasten death
  • existential anxiety/suffering

Additional high-complexity examples (psychological/emotional and conflict)

• Communication conflict:
  • between patient and family
  • between patient and the therapeutic team
• Emotional/adaptive distress

Family/environment examples

• “Four or five points” described as highly complex (subtitle unclear on exact thresholds)
• Complex grief mentioned as an example of complex (not highly complex)
• Highly complex includes examples such as:
  • absence/insufficiency of caregiver/family support
  • caregivers not competent for care
  • dysfunctional family structure harming care
  • structural environmental limitations (e.g., living on an island)

Healthcare organization/team/resource examples

• Difficulty prescribing/managing medications
• Difficulty prescribing/managing interventions
• Limitations in professional competence for certain situations
• Difficulty managing instrumental techniques/materials
• Logistical coordination difficulties

Service organization implication

• More complex cases may require both primary/secondary and eventually specialized consultation.
• Subtitles state:
  • highly specialized teams should respond to highly complex needs
  • but complexity does not strictly determine where treatment occurs; local organization matters.

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Method for applying the scales in practice (workflow/instructions)

• Use functional scales (Karnofsky, ECOG/PS, PPS) to assess functionality/need level.
• Use NECPAL to identify palliative needs early:
  • apply the Surprise Question
  • review medical record-based criteria
  • apply staging/version guidance (e.g., Chile standard version 3.0 mentioned)
• Determine complexity level using NECPAL domains to guide whether management should occur in:
  • primary, secondary, or both levels
  • and whether consultation with a specialized palliative care team is needed
• Apply findings to local care network reality:
  • choose the care level based on what is available locally
  • if no specialized center exists, rely on a functional network
• Use scales as guidance, not rigid rules:
  • scales guide decision-making but should not replace comprehensive clinical assessment or clinician judgment.

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Clinical case example (for reflection/assignment)

Patient profile

• 80-year-old person living with a 76-year-old wife
• Diagnoses/history:
  • insulin-dependent diabetes mellitus
  • chronic liver damage
  • hypertension
  • long-standing diabetes mellitus
• Hospitalizations:
  • more than 3 hospitalizations in the last year for pneumonia and parasitism (subtitle wording unclear, but repeated admissions are emphasized)

Functional decline

• Two children: one in Puerto Montt, one in Santiago
• Increased dependency:
  • can only get up with help to use the bathroom
  • partial support needed for dressing and eating

Symptoms

• dyspnea
• progressive dysphagia
• intermittent pain
• delirium

Care referral context

• Referred from the emergency room after the most recent hospitalization to universal palliative care.

Assignment stated

• Apply the reviewed scales to decide:
  • where the patient can be treated
  • and/or at what level of care
  • based on local network reality.

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Speakers / sources featured

• No individual speaker name is provided in the subtitles.
• Organizations/sources mentioned:
  • Observatory (developer of NECPAL; within a collaborating center referenced in subtitles)
  • UMS (mentioned as part of the collaborating center; full name not provided)
  • Catalan Institute of Oncology
  • Cuos Peliaos program (technical guidelines; exact expansion unclear due to subtitle errors)
  • Chilean health context with discussion of NECPAL versions 3.0 and 4.0