Is it time for Hospice or Palliative care? 1. Have you been diagnosed with a serious, life-limiting illness? These include (but are not limited to): AIDS Alzheimer's Disease Cancer Congestive Heart Failure (CHF) Digestive Disease Heart/Cardiovascular Disease Kidney Disease Liver Disease Neurological Conditions (Dementia, Parkinson’s, MS, ALS, Huntington’s Disease, Stroke) Renal Disease Yes No 1 out of 5 2. Has there been a recent change in your condition? Some examples might include: Loss of interest in daily activities Increasing falls or unsteadiness Increasing usage of a cane, walker or wheelchair More difficulty swallowing Increase in daytime sleeping Progressive, unintentional weight loss Uncontrollable disease related pain with current medications Shortness of breath, even while resting Deteriorating mental abilities Yes No 2 out of 5 3. Have you found yourself needing more medical support? Yes No 3 out of 5 4. Have you started to need more help to perform daily activities? These include: Bathing Dressing Eating Walking Getting out of bed Yes No 4 out of 5 5. Would you like to focus on quality of life rather than life-prolonging treatments? Yes No 5 out of 5 Time is Up! Time's up
