2.3 Prognostic and Functional Assessment Tools
Key Takeaways
- The Palliative Performance Scale (PPS) rates ambulation, activity, self-care, intake, and consciousness from 100 to 0 in 10-point steps; PPS 70 is reduced ambulation with full self-care, PPS 40 is mainly in bed with mainly assistance, and PPS 20 is totally bed bound with total care and minimal sips.
- Functional Assessment Staging (FAST) stages Alzheimer-type dementia; hospice recertification conversations often turn on stage 7 substages such as speech limited to a few words and loss of independent ambulation.
- The Palliative Prognostic Index combines PPS, oral intake, edema, dyspnea at rest, and delirium; higher scores are associated with shorter survival measured in weeks.
- Karnofsky Performance Status, Eastern Cooperative Oncology Group performance status, and New York Heart Association class are disease-context tools the CHPN still uses in oncology and heart-failure palliative care.
- Documented functional decline supports hospice recertification; when patients cannot self-report, use nonverbal pain and distress cues rather than assuming absence of suffering.
2.3 Prognostic and Functional Assessment Tools
Domain 1 does not ask you to memorize a survival-curve textbook. It asks whether you can describe function clearly enough that the IDG, the certifying physician, and a later recertification visit all see the same patient. Prognosis in hospice is a clinical synthesis: diagnosis, trajectory, and function. Function is what the CHPN measures every visit. Tools do not replace judgment. They keep language consistent when one nurse says declining and another says about the same.
Hospice recertification still requires a physician or nurse practitioner to certify that the patient is terminally ill — a life expectancy of 6 months or less if the illness runs its normal course. Sequential drop in performance status, increasing dependence, falling oral intake, and new delirium are the nursing observations that make that certification defensible. A single good day does not erase a month of PPS decline.
Palliative Performance Scale
The Palliative Performance Scale (PPS) rates five domains — ambulation, activity and evidence of disease, self-care, intake, and level of consciousness — from 100 (fully active) to 0 (death) in 10-point increments. Score the current observed function, not the family's hoped-for function and not the patient's best hour last week.
| PPS | Ambulation | Activity and disease | Self-care | Intake | Consciousness | How a CHPN uses it |
|---|---|---|---|---|---|---|
| 70 | Reduced | Significant disease | Full | Normal or reduced | Full | Still largely independent; common in early hospice or palliative clinic; may not look dying to relatives |
| 50 | Mainly sit or lie | Extensive disease | Considerable assistance | Normal or reduced | Full or confusion | Rising caregiver load; visit frequency often increases |
| 40 | Mainly in bed | Extensive disease | Mainly assistance | Normal or reduced | Full or drowsy, with or without confusion | Typical mid-trajectory home hospice; transfers and bathing need hands-on help |
| 30 | Totally bed bound | Extensive disease | Total care | Reduced | Full or drowsy, with or without confusion | High acuity at home; consider whether the current level of care still matches need |
| 20 | Totally bed bound | Extensive disease | Total care | Minimal sips | Full or drowsy, with or without confusion | Late disease; recertification is usually straightforward if decline is documented |
| 10 | Totally bed bound | Extensive disease | Total care | Mouth care only | Drowsy or coma, with or without confusion | Actively dying pattern for many diagnoses; prepare the family |
A PPS of 70 versus 40 versus 20 is a favorite exam contrast. PPS 70 patients still perform self-care; calling them total care is a scoring error. PPS 20 patients take minimal sips and cannot get out of bed; calling them independent is a scoring error. Do not average a morning of sitting up with a night of unresponsiveness into a polite 50 if the dominant picture is PPS 20.
Karnofsky Performance Status
The Karnofsky Performance Status (KPS) is a 0–100 oncologic scale that predates PPS. KPS 70 is able to care for self but unable to carry on normal activity or work. KPS 40 is disabled and requires special care and assistance. KPS 20 is very sick. PPS was designed to be more hospice-specific (intake and consciousness are explicit). If a chart mixes KPS and PPS, do not treat the numbers as interchangeable without reading the descriptors. On the CHPN exam, if the stem says PPS, use PPS rules.
FAST in dementia
Functional Assessment Staging (FAST) stages Alzheimer-type dementia from 1 (normal) through 7 (loss of all speech, ambulation, and basic motor control). Stages 1–5 cover subjective forgetfulness through needing help choosing clothes. Stage 6 covers dressing, bathing, toileting mechanics, and incontinence. Stage 7 substages are the ones hospice recertification arguments actually use:
- 7a: Speech limited to about six intelligible words or fewer in an average day
- 7b: Speech limited to one intelligible word
- 7c: Independent ambulation lost
- 7d–7f: Cannot sit up independently, smile, or hold the head up
Medicare local coverage determinations for dementia hospice commonly look for FAST stage 7 plus comorbidities or secondary conditions (aspiration, pyelonephritis, decubitus ulcers, weight loss). The CHPN documents the FAST substage with observed examples (said only no today; two-person pivot) rather than writing advanced dementia. FAST is not a universal tool for every non-Alzheimer dementia, but it is the language the exam and many recertification notes still use.
NYHA class in heart failure
New York Heart Association (NYHA) functional class describes heart-failure symptom limitation:
- Class I: no limitation of ordinary activity
- Class II: slight limitation; ordinary activity causes symptoms
- Class III: marked limitation; less than ordinary activity causes symptoms
- Class IV: unable to carry on any physical activity without discomfort; symptoms may be present at rest
Hospice and palliative planning for heart failure often centers on class III–IV, recurrent hospitalizations, and hypotension or renal decline that limits disease-directed therapy. NYHA class can improve with diuresis; score today's limitation, and pair it with trajectory (third admission this quarter) rather than treating a single class label as a permanent stage.
Palliative Prognostic Index
The Palliative Prognostic Index (PPI) is a composite used in palliative populations. It combines:
- PPS (lowest bands carry the most points)
- Oral intake (moderately or severely reduced)
- Edema
- Dyspnea at rest
- Delirium
Higher PPI scores are associated with shorter survival, typically measured in weeks rather than months. You do not need to memorize every decimal weight for the exam, but you must recognize the pattern: function plus intake plus edema plus rest dyspnea plus delirium. A patient with PPS 20, sips only, leg edema, dyspnea at rest, and fluctuating delirium is not a PPI surprise. A patient with PPS 70, normal intake, no edema, no rest dyspnea, and clear sensorium should not be described as hours to days on the basis of a family hunch alone.
PPI does not replace diagnosis-specific signs (ejection fraction, tumor burden, FAST stage). It organizes nursing observations the IDG can reuse at recertification.
ECOG in oncology palliative care
The Eastern Cooperative Oncology Group (ECOG) performance status is the oncology scale you will see in palliative clinic:
- 0: fully active
- 1: restricted in strenuous activity, ambulatory, able to do light work
- 2: ambulatory, all self-care, up and about more than 50% of waking hours
- 3: limited self-care, confined to bed or chair more than 50% of waking hours
- 4: completely disabled, totally confined to bed or chair
- 5: dead
ECOG 3–4 often tracks with hospice-range function in solid tumors. ECOG 2 patients may still be in disease-directed therapy with a concurrent palliative plan. Do not convert ECOG to PPS by doubling; the descriptors differ, especially around intake.
Function, recertification, and nonverbal assessment
Documented decline — serial PPS drops, FAST 7 progression, worsening NYHA class, falling intake, new dependence for transfers — supports continued hospice eligibility. A plateau does not automatically mandate live discharge, but it does mandate an honest IDG review of terminal prognosis. Improvement that is sustained, with function incompatible with a 6-month prognosis, is a reason to plan live discharge for no longer terminally ill, with teaching and community referrals.
When patients cannot self-report, do not conclude they have no pain or dyspnea. Watch the face, vocalization, body tension, guarding, resistance to turning, tachypnea, and restlessness. Tools such as Pain Assessment in Advanced Dementia (PAINAD) structure those observations. Treat distress while you search for causes (urinary retention, wound, delirium). Quiet is not comfort.
A home-hospice nurse is teaching a new colleague how to interpret the Palliative Performance Scale. Which statement is accurate?
Which tool is specifically designed to stage function in Alzheimer-type dementia for care planning and hospice recertification discussions?
The Palliative Prognostic Index used in palliative populations is built from which pattern of observations?