Standardized Ratings for Clinician Use When Patient Is Unable To Rate Symptoms 1 2 3 4 5 1. Vomiting None 1 episode in 24 hours 2-5 episodes in 24 hours > 6 episodes in 24 Intractable/ No oral hours intake 1 2 3 4 5 4. Tachypnea 5HVSLUDWRU\5DWH Respiratory Rate 19-25 Respiratory Rate 26-32 Respiratory Rate 33-39 5HVSLUDWRU\5DWH 1 2 3 4 5 None Requires stool softener Requires stool softener Requires Bowel Obstruction 9. Constipation and laxative enema/disimpact or 0 BM: 3-4 d 1 2 3 4 5 57. Depressed Level None Somnolence or sedation Somnolence or sedation Obtunded or stupor; Coma of Consciousness not interfering with interfering with function but difficult to arouse; (LOC)* function not ADLs interfering with ADLs 1 2 3 4 5 None Disorientation or attention Disorientation or attention Confusion or delirium Harmful to others or 58. Agitated Delirium* deficit of brief duration; deficit interfering with interfering with ADLs self; requiring sitter or resolves spontaneously function, but not with ADLs restraints Derived from ECOG Common Toxicity Criteria Manual, Version 2 Pain Assessment IN Advanced Dementia (PAINAD) 0 1 2 Scores Breathing Normal Occasional labored breathing. Short period of Noisy labored breathing. Long period of Independent of hyperventilation hyperventilation. Cheyne-stokes respirations vocalization Negative None Occasional moan or groan. Low level speech Repeated troubled calling out. Loud moaning Vocalization with a negative or disapproving quality or groaning. Crying Facial expression Smiling, or inexpressive Sad. Frightened. Frown Facial grimacing Relaxed Tense. Distressed pacing. Fidgeting Rigid. Fists clenched, knees pulled up, pulling Body Language or pushing away, striking out Consolability No need to console Distracted or reassured by voice or touch Unable to console, distract or reassure Score Total Warden, Hurley, Volicer, JAMDA 2003; 4(1): 9-15 PALLIATIVE PREFORMANCE SCALE/SCORE % Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level 10 100% Full Normal Activity No Evidence of Disease Full Normal Full 90% 9 Full Normal Activity Some Evidence of Disease Full Normal Full Full Normal Activity With Effort 8 80% Full Normal/Reduced Full Some Evidence of Disease Unable Normal Job/Work 7 70% Reduced Full Normal/Reduced Full Some Evidence of Disease Reduced 6 60% Unable Hobby/House work Significant Disease Occasionally Assist Necessary Normal/Reduced Full/Confusion 5 50% Mainly Sit/Lie Unable to Do Any Work Extensive Disease Considerable Assist Necessary Normal/Reduced Full/Confusion 4 40% Mainly in Bed As Above Mainly assist Normal/Reduced Full/Drowsy/Coma 30% Totally Bed 3 As Above Total care Reduced Full/Drowsy/Coma Bound 20% 2 As Above As Above Total Care Minimal Sips Full/Drowsy/Coma 1 10% As Above As Above Total Care Mouth Care Only Drowsy/Coma 0 0% Death Symptom Scale 1. Nausea I do not feel nauseated at all 1 2 3 4 5 9 I feel as nauseated as I could possibly be 2. Depression Not sad at all 1 2 3 4 5 9 Could not feel more sad 3. Anxiety Not anxious at all 1 2 3 4 5 9 Could not feel more anxious 4. Appetite Normal appetite 1 2 3 4 5 9 Worst appetite I have ever had 5. Shortness of breath Normal breathing 1 2 3 4 5 9 Worst SOB I have ever had 6. Insomnia Perfect sleep 1 2 3 4 5 9 0\VOHHSFRXOGQ¶WEHZRUVe 7. Pain No pain 1 2 3 4 5 9 Worst pain I have ever had 8. Constipation No constipation 1 2 3 4 5 9 The worst constipation I have ever had 9. Agitated delirium 1 2 3 4 5 9 10. Decreased LOC 1 2 3 4 5 9 Modified from the Symptom Distress Scale (McCorkle, 1978), and the Missoula-VITAS QOL ± subset (Byock, 1995) .