Is It Time for Hospice or Palliative Care? Hospice or Palliative Care Self-Assessment This self assessment will help you determine what care may be right for you or a loved one. Assessment results do not guarantee admission for care but can be used as a guide to get the conversation started. Please contact Hospice of St. Lawrence Valley at any time if you would like more information about Hospice or AIM services! 1. Have you been diagnosed with a serious, life-limiting illness? These include (but are not limited to): Chronic obstructive pulmonary disease (COPD) Dementia 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? These include (but are not limited to): 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? Are you calling your primary or specialty doctor more often? Have you started new or stronger pain medication? Are you needing supplemental oxygen? Have you had recurrent infections? Have you visited the emergency room or been hospitalized three or more times for the same symptoms in the past six months? Yes No 3 out of 5 4. Have you or someone else started to need more help to perform any of the following daily activities? These Include (But not limited to): 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
