What is the CASL-2 assessment?
Summary
The PPS scale (Palliative Performance Scale) is a validated functional assessment tool developed in 1996 that measures five domains—ambulation, activity level, self-care, oral intake, and consciousness—to evaluate patients in palliative care settings.
PPS scores range from 0% (death) to 100% (fully healthy) in 10-point increments, with PPS scale hospice eligibility typically indicated by scores of 70% or below for cancer patients and 50% or below for non-cancer conditions.
Understanding how to use the PPS scale calculator approach involves reading left to right across domains, applying leftward dominance when columns conflict, and using clinical judgment to determine the best horizontal fit.
Mental health therapists, nurse practitioners, and hospice and palliative care clinicians can use the PPS scale for workload assessment, prognosis determination, and communicating patient functional status in integrated palliative care settings.
The PPS scale or Palliative Performance Scale was first introduced by Fern Anderson and Michael Downing in 1996 as a tool to measure functional performance status in palliative care.
For mental health therapists and nurse practitioners working in private practice or integrated care settings, understanding the PPS scale provides valuable insights into patient functioning and end-of-life care needs.
Why was a specialized palliative assessment tool needed?
The PPS scale was created as a modification of the Karnofsky Performance Scale (KPS). Its initial uses in Victoria Hospice in Victoria, British Columbia, Canada focused on communication, analysis of home nursing care workload, profiling, and admissions and discharges within the hospice unit.
Commonly used prognostic tools, such as the Karnofsky Performance Scale, do not take into account the continued fluctuations in oral intake or the level of consciousness once a client becomes bedridden.
Scales for the palliative care population were needed to analyze this aspect of the client’s life more comprehensively, and thus, the Palliative Performance Scale was developed.
Unlike other assessment tools that depend on diagnosis, the PPS scale is function focused. This allows team members the ability to quickly capture the real-world condition of clients.
Functional performance status is a major contributing factor in prognosis and in determining the best treatment for a client, as it assesses the patient's ability to perform activities of daily living.
Activities of daily living include personal hygiene, toileting, continence, eating, dressing, and mobility.
The PPS scale measures five functional domains
The PPS scale measures five functional domains with each domain being divided into 11 levels.
The five domains include ambulation, activity level and evidence of disease, self-care, oral intake, and level of consciousness.
Within each domain, there are 11 levels ranging from 0 to 100 percent, which are then divided in 10 percent-point intervals. In these intervals, 0 percent indicates the client is dead and 100 percent indicates the client is fully ambulatory and healthy.
Ambulation domain
Regarding the ambulation domain, there are five descriptions: Full, reduced ambulation, mainly sit/lie, mainly in bed, and totally bed bound.
Full refers to no restrictions or assistance.
Reduced ambulation refers to the degree to which the client walks and transfers with occasional assistance.
Mainly sit/lie and mainly in bed refer to the amount of time the client is able to sit up or needs to lie down.
Lastly, totally bed bound refers to the client being unable to get out of bed or perform self-care activities.
Activity level and evidence of disease domain
In the activity and evidence of disease domain, there are two sections.
First, the activity and job/work section.
Activity refers to the normal activities linked to daily routines, housework, and hobbies/leisure.
Job/work refers to the normal activities linked to both paid and unpaid work, including homemaking and volunteer activities.
The next section addresses evidence of disease.
Within this section, no evidence of disease refers to the client being healthy, with no physical or investigative evidence of disease.
Terms such as “some,” “significant,” and “extensive” disease refer to physical and investigative evidence showing disease progression. This section can be complex, so let’s go over an example of a disease process and how it would be categorized.
For example, with congestive heart failure:
“Some” disease could include the client taking diuretics and guideline-directed medical therapy (GDMT) medications on a daily basis for the management of heart failure.
“Significant” disease could include a heart failure exacerbation such as shortness of breath due to pulmonary effusions or edema that requires modifications of the treatment plan due to the original plan not stabilizing the disease process.
“Extensive” disease could refer to multiple hospitalizations and an overall decline in the management of heart failure and its symptoms such as hypotension.
Self-care domain
The self-care domain includes: Full, occasional assistance, considerable assistance, mainly assistance, and total care.
Full means the client is able to do traditionally normal activities such as sitting on the side of the bed, getting out of bed, walking, bathing, using the toilet, and eating without assistance.
Occasional assistance refers to the client requiring minor assistance with frequency ranging from once daily to multiple times a week.
Considerable assistance is selected when the client requires moderate assistance every day, but only for some of the activities of daily living.
Mainly assistance is major assistance every day, for most of the activities of daily living, although the client can eat with minimal to no support.
Finally, total care means the client always requires assistance for all care aspects, with the client being able or unable to chew and swallow food.
Oral intake domain
The oral intake domain has four sections: Normal, normal or reduced, minimal to sips, and mouth care only.
In the normal section, the client eats normal amounts of food for a healthy individual.
Normal or reduced refers to normal intake, but with periods of reduced intake that is less than the normal amount a healthy individual would consume.
Minimal to sips means that the client’s intake consists of very small amounts, usually pureed or liquid, with the intake being below normal.
Lastly, mouth care only refers to no oral intake at all.
Level of consciousness domain
The final domain is level of consciousness.
In this domain, there are four sections: Full, full or confused, full or drowsy with or without confusion, and drowsy or comatose with or without confusion.
Full refers to the client being fully alert and oriented with normal cognitive abilities such as thinking and memory.
Full or confusion is when the client’s level of consciousness is full or may be reduced. If reduced, confusion denotes delirium or dementia, which can range from mild, moderate, or severe, with varying etiologies.
Full or drowsy with or without confusion refers to a full or markedly reduced level of consciousness. This can include periods of stupor or fatigue. This section suggests fatigue, drug side effects, delirium, or closeness to death.
Finally, drowsy or comatose with or without confusion means there is no response to verbal or physical stimuli with some reflexes being absent. If the client is in a coma, the depth of the coma may fluctuate.
How to use the PPS scale
Now that we understand what the PPS scale includes, let's review how to use it as a PPS scale calculator for patient assessment.
The Palliative Performance Scale is completed by the clinician reading the scale from left to right, finding the best descriptor or horizontal fit for the client.
Step-by-step assessment process:
1. Start with ambulation: The clinician starts at the left column reading each option until the appropriate ambulation is chosen.
2. Move across each domain: The clinician reads across the next column and downwards until the most appropriate choice is made, and so forth.
3. Apply leftward dominance: Typically, the leftward columns take precedence over the rightward columns.
4. Use clinical judgment: Often, one or two columns may be applicable, but the clinician should select the best fit for the client. Clinical judgment and the leftward dominance rule should be used to determine the most accurate score.
Important scoring considerations
PPS scores are in 10-percent increments only.
Therefore, a clinician choosing a score of 45 percent is not correct.
The clinician must use leftward dominance and clinical judgement to determine if the client’s best fit is either 40 or 50 percent, for example.
Determining hospice eligibility and prognosis
The PPS score is important for many reasons, but one major reason is its ability to determine hospice eligibility through PPS scale hospice criteria.
For most oncology clients, a PPS score of 70 percent or below generally indicates hospice eligibility.
For other life-threatening non-cancer disease processes such as Alzheimer’s disease, chronic obstructive pulmonary disease, or advanced heart failure, a PPS score of 50 percent or below indicates hospice eligibility.
Clinical considerations for mental health clinicians and nurse practitioners
For mental health therapists and nurse practitioners in private practice or integrated care settings, familiarity with the PPS scale offers several advantages.
Interdisciplinary collaboration
Understanding the PPS scale facilitates communication with palliative care teams, hospice providers, and medical colleagues.
Holistic assessment
The PPS scale's inclusion of consciousness levels makes it particularly relevant for mental health professionals monitoring cognitive changes and delirium.
Treatment planning
PPS scores can inform the appropriateness and intensity of mental health interventions, helping clinicians adjust therapeutic approaches based on functional status.
Family support
Mental health professionals can help families understand what different PPS scores mean for their loved one's trajectory and prepare for end-of-life transitions.
Ethical decision-making
The PPS scale provides objective data that supports discussions about goals of care, advance directives, and quality of life considerations.
Conclusion
The PPS scale remains an essential tool in palliative and end-of-life care, providing a standardized, function-focused approach to assessing patient status.
For mental health therapists and nurse practitioners, understanding how to interpret and apply PPS scores enhances their ability to provide comprehensive, compassionate care to patients and families navigating serious illness and end-of-life transitions.
Sources
Ho, F., Lau, F., Downing, M. G., & Lesperance, M. (2008). A reliability and validity study of the palliative performance scale. BMC Palliative Care, 7(10), 1-10.
Baik, D., Russell, D., Jordan, L., Dooley, F., Bowles, K., & Masterson Creber, R. M. (2018). Using the palliative performance scale to estimate survival for patients at the end of life: A systematic review of the literature. Journal of Palliative Medicine, 21(11), 1651-1661.
Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative performance scale (PPS): A new tool. Journal of Palliative Care, 12(1), 5-11.
National Palliative Care Research Center. (n.d.). Palliative performance scale PPSv2.
Shega, J. (n.d.). Hospice eligibility guidelines. Vital Healthcare.
Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (2007). Validation of the palliative performance scale in the acute tertiary care hospital setting. Journal of Palliative Medicine, 10(1), 111-117.
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