gpraj

View Original

The Gold Standards Framework

Dr Rajesh Varma

Gold Standards Framework

The GSF PIG 2016 (6th Edition) Proactive Identification Guidance 

GSF is a systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by generalist frontline care providers.

Aim
To enable the earlier identification of people nearing the end of their life who may need additional supportive care and advance care planning discussions

People to be considered

People nearing the end of life following the three main trajectories of illness for expected death

  1. Rapid predictable decline e.g. cancer

  2. Erratic unpredictable decline e.g. organ failure

  3. Gradual decline e.g. frailty, dementia or multi-morbidity

Strategy
Does the patient fulfil the GMC definition of End of Life Care; ‘People are ‘approaching the end of life’ when they are likely to die within the next 12 months. 
If unsure, then, screen for General Indicators of Decline
If still unsure, then screen for Specific Clinical Indicators

General indicators of decline

  1. General physical decline, increasing dependence and need for support.

  2. Repeated unplanned hospital admissions.

  3. Advanced disease - unstable, deteriorating, complex symptom burden.

  4. Presence of significant multi-morbidities.

  5. Decreasing activity – functional performance status declining (e.g. Barthel score) limited self-care, in bed or chair 50% of day and increasing dependence in most activities of daily living.

  6. Decreasing response to treatments, decreasing reversibility.

  7. Patient choice for no further active treatment and focus on quality of life.

  8. Progressive weight loss (>10%) in past six months. 

  9. Sentinel Event e.g. serious fall, bereavement, transfer to nursing home.

  10. Serum albumin <25g/l.

  11. Considered eligible for DS 1500 payment.

Specific Clinical Indicators related to three trajectories (Abridged version)


CANCER (rapid predictable decline)

Not amenable to treatment
Spending more than 50% of time in bed
Prognosis estimated in months

ORGAN FAILURE (erratic unpredictable decline)

Heart Disease 
Shortness of breath at rest on minimal exertion (NYHA Stage 3 or 4).
Repeated admissions with heart failure – 3 admissions in 6 months or a single admission aged over 75 (50% 1yr mortality)
Hyponatraemia <135 mmol/l
Declining renal function

Chronic Obstructive Pulmonary Disease (COPD) 
Recurrent hospital admissions (at least 3 in last year due to COPD)
MRC grade 4/5 – shortness of breath after 100 metres on level
FEV1 <30% predicted)
Fulfils long term oxygen therapy criteria (PaO2<7.3kPa).
Right heart failure

Kidney Disease 
Stage 4 or 5 Chronic Kidney Disease (CKD)
Repeated unplanned admissions (more than 3/year)
Nausea and vomiting, anorexia, pruritus, reduced functional status
Intractable fluid overload

Liver Disease 
Hepatocellular carcinoma
Advanced cirrhosis with complications including: refractory ascites, encephalopathy

General Neurological Diseases 
Swallowing problems (dysphagia) leading to recurrent aspiration pneumonia, sepsis, breathlessness or respiratory failure.
Speech problems: progressive dysphasia.

Parkinson’s Disease 
The condition is less well controlled with increasing “off” periods.
Dyskinesias, mobility problems and falls.
Psychiatric signs (depression, anxiety, hallucinations, psychosis)

Motor Neurone Disease 
First episode of aspirational pneumonia.
Increased cognitive difficulties.
Low vital capacity (below 70% predicted spirometry), or initiation of NIV.

Multiple Sclerosis 
Dysphagia + poor nutritional status.
Communication difficulties e.g., Dysarthria + fatigue.
Cognitive impairment notably the onset of dementia.

FRAILTY, DEMENTIA OR MULTI-MORBIDITY (Gradual decline)

Frailty 
Comprehensive Geriatric Assessment (CGA)
Slow Walking Speed – takes more than 5 seconds to walk 4 m.
TUGT – time to stand up from chair, walk 3 m, turn and walk back. 
PRISMA – at least 3 of the following: Do you have health problems that cause require you to stay at home?, In case of need can you count on someone close to you?
Do you regularly use a stick, walker or wheelchair to get about?

Dementia 
Functional Assessment Staging has utility in identifying the final year of life in dementia. (BGS)
Unable to walk without assistance
Urinary and faecal incontinence
No consistently meaningful conversation and
Unable to do Activities of Daily Living (ADL)
Barthel score <3
Reduced oral intake
Aspiration pneumonia.

Stroke 
Use of validated scale such as NIHSS recommended.
Cognitive impairment / Post-stroke dementia.