DementiaRoadmap

This guidance aims to help GPs, clinicians and other professionals in earlier identification of those adult patients nearing the end of their life who may need additional support.

Download Gold Standard Framework Prognostic Indicator Guidance

About 1% of the population die each year. Although some deaths are unexpected, many more in fact can be predicted. This is inherently difficult, but if we were better able to predict people in the final year of life, whatever their diagnosis, and include them on a register, there is good evidence that they are more likely to receive well-co-ordinated high quality care.

Once identified, they can be placed on a register such as the GP’s QOF palliative care register, hospital flagging system or locality register. This in turn can trigger specific support, such as clarifying their particular needs, offering advance care planning discussions prevention of crises admissions and pro-active support to ensure they ‘live well until they die’.

Three triggers that suggest that patients are nearing the end of life are:

1. The Surprise Question: “Would you be surprised if this patient were to die in the next few months, weeks, days?”
2. General indicators of decline – deterioration, increasing need or choice for no further active care.
3. Specific clinical indicators related to certain conditions.

This is in line with thinking on shared decision-making processes and the importance of integrating advance care planning discussions into delivery of care. It is based on consideration of people’s needs rather than exact timescales, acknowledging that people need different things at different times.