As a patient nears the end of life, it can be tough to find the right time to adjust their care. Although a physician’s professional judgment remains the key factor, the Palliative Performance Scale (PPS) can help in the process.
The PPS is a validated and reliable tool that can be used to assess your patient’s ability to function and determine how to move toward the end of life, including when to have goals-of-care conversations with patients and families.
Hospice care may be appropriate for patients with a PPS score of less than 70%. For these patients, survival for more than 6 months is unlikely.
Learn about the PPS to better understand how to support your patients as they approach the end of life.
How to Use the PPS
The PPS helps physicians determine how to best support their patients. Below is a chart that assigns a PPS level based on a patient’s individual needs.
| PPS Level | Ambulation | Activity and Evidence of Disease |
Self-Care | Intake | Conscious Level |
|---|---|---|---|---|---|
STABLE |
|||||
| 100% | Full | Normal activity and work / No evidence of disease | Full | Normal | Full |
| 90% | Full | Normal activity and work / Some evidence of disease | Full | Normal | Full |
| 80% | Full | Normal activity with effort / Some evidence of disease | Full | Normal or reduced | Full |
HOSPICE APPROPRIATE |
|||||
| 70% | Reduced | Unable to do normal job or work / Significant disease | Full | Normal or reduced | Full |
| 60% | Reduced | Unable to do hobby or housework / Significant disease | Occasional assistance necessary | Normal or reduced | Full confusion |
| 50% | Mainly sit/lie | Unable to do any work / Extensive disease | Considerable assistance required | Normal or reduced | Full confusion |
| 40% | Mainly in bed | Unable to do most activity / Extensive disease | Mainly assistance | Normal or reduced | Full or drowsy +/- confusion |
| 30% | Totally bedbound | Unable to do any activity / Extensive disease | Total care | Normal or reduced | Full or drowsy +/- confusion |
| 20% | Totally bedbound | Unable to do any activity / Extensive disease | Total care | Minimal to sips | Full or drowsy +/- confusion |
| 10% | Totally bedbound | Unable to do any activity / Extensive disease | Total care | Mouth care only | Full or drowsy +/- confusion |
| 0% | Death | – | – | – | – |
PPS Terms Defined
Some terms on the PPS have similar meanings, but differences in meaning will become easier to identify as you move through the chart. The goal is to find an overall best fit using all five columns on the chart. Here is an explanation of each term to help you get started.
Ambulation refers to moving or walking around.
Reduced ambulation is at both the 70% and the 60% levels on the PPS. According to the column to the right, reduced ambulation is when a patient is unable to carry out their normal job, work duties, or some hobbies or housework activities. The person is still able to walk on their own — but at PPS 60%, they need assistance from time to time.
The items mainly sit/lie (PPS 50%), mainly in bed (PPS 40%), and totally bedbound (PPS 30%, 20%, and 10%) are similar. The minor differences are related to items in the self-care column. For example, totally bedbound at PPS 30% is due to either major weakness or paralysis: the patient not only can’t get out of bed but also is unable to do any self-care.
The difference between mainly sit/lie and mainly in bed is the amount of time the patient is able to sit up compared to their need to lie down.
Some, significant, and extensive disease refer to evidence that shows degrees of progression.
For example, for a patient with breast cancer:
- Some disease would be a local recurrence.
- Significant disease would be one or two metastases in the lungs or bones.
- Extensive disease would be multiple metastases in the lungs, bones, liver, or brain; hypercalcemia; or other major complications.
The evidence may also refer to progression of disease despite active treatments. Using AIDS as an example:
- Some disease may mean the shift from HIV to AIDS.
- Significant implies progression in physical decline, new or difficult symptoms, and laboratory findings with low counts.
- Extensive refers to one or more serious complications with or without continuation of active antiretrovirals, antibiotics, etc.
Evidence of disease is also determined alongside a patient’s ability to take part in work, hobbies, or activities. Decline in activity may mean the person still plays golf, but they now play 9 holes compared to 18, or they stick to backyard putting. People who enjoy walking will gradually walk shorter distances, although they may continue trying.
- Occasional assistance means that patients are usually able to transfer out of bed, walk, wash, use the toilet, and eat on their own. However, sometimes — once a day or a few times a week — they need minor assistance.
- Considerable assistance means that the patient needs help regularly every day — usually by one person — to do some of the activities noted above. For example, they may need help to get to the bathroom, but then they’re able to brush their teeth or wash their hands and face. As for eating, food will often need to be cut into smaller sizes, but the patient eats on their own.
- Mainly assistance is a further extension of considerable assistance. Using the above example, the patient now needs help getting up and washing their face and shaving. However, they can usually eat with minimal or no help. This may fluctuate according to fatigue during the day.
- Total care means that the patient is completely unable to eat, use the toilet, or do any self-care without help. Depending on the clinical situation, the patient may or may not be able to chew and swallow food prepared for them.
Intake refers to food intake, and changes are usually noticeable:
- Normal intake refers to the person’s usual eating habits while healthy.
- Reduced means any reduction from that, and this depends on the person’s unique individual situation.
- Minimal refers to very small amounts of food — usually pureed or liquid — that are well below nutritional sustenance.
- Full consciousness implies full alertness and orientation with good cognitive abilities in thinking, memory, etc.
- Confusion implies presence of either delirium or dementia and is a reduced level of consciousness. It may be mild, moderate, or severe with multiple possible causes.
- Drowsiness implies either fatigue, side effects from medication, delirium, or closeness to death and is sometimes included in the term “stupor.”
- Coma, in this context, is the absence of response to verbal or physical stimuli, and some reflexes may or may not remain. The depth of coma may fluctuate throughout a 24-hour period