Is It Time for Hospice or Palliative Care? Hospice or Palliative Care Self-Assessment Quiz This self assessment quiz will help you determine what care is right for you or a loved one. Quiz results do not guarantee admission for care and requires further inquiry for criteria with us. However, it can be used as a guide to get the conversation started. 1. Have you or someone else been diagnosed with a serious, life-limiting illness? These include (but are not limited to): Select any that apply 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 None of the Above 1 out of 6 2. From the previous diagnosed illnesses have you or a loved one been given a terminal diagnosis of 6 months or less? Yes No 2 out of 6 3. Has there been a recent change in your/their condition? Select any of the following examples that apply 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 3 out of 6 4. Have you found yourself needing more medical support? Yes No 4 out of 6 5. Have you or someone else started to need more help to perform any of the following daily activities? (Select all that apply) Bathing Dressing Eating Walking Getting out of bed None of the above 5 out of 6 6. Would you or someone you know like to focus on quality of life rather than life-prolonging treatments? Yes No 6 out of 6 Please fill in the comment box below. Full Name City, State, Zip Email Phone Are you taking this quiz for information for yourself or someone else? If for someone else, please list relation (Health care proxy, primary caregiver, provider, family member or neighbor) Time is Up! Time's up
