Palliative Performance Scale (PPS)

The Palliative Performance Scale (PPS) is a validated and reliable tool used to assess a patient’s functional performance and to determine progression toward end of life. However, it does not take the place of a physician’s professional judgment.

This scale can be a helpful reference for clinicians in timing the goals-of-care conversation with patients and their families.

Patients with a PPS score of < 70% may be appropriate for hospice care. Research substantiates, for these patients, survival for greater than six months is unlikely.¹

Would you be surprised if this patient lived longer than one year?

Definition of Terms for PPS

As noted below, some of the terms have similar meanings, with the differences being more readily apparent as one reads horizontally across each row of the chart to find an overall best fit using all five columns.

Ambulation

Reduced ambulation is located at the PPS 70% and PPS 60% level. By using the adjacent column, the reduction of ambulation is tied to the patient’s inability to carry out their normal job, work occupation, or some hobbies or housework activities. The person is still able to walk and transfer on their own but at PPS 60% needs occasional assistance.

The items mainly sit/lie, mainly in bed, and totally bed bound are clearly similar. The subtle differences are related to items in the self-care column. For example, totally bed bound at PPS 30% is due to either profound weakness or paralysis such that the patient not only can’t get out of bed but is also unable to do any self-care.

The difference between mainly sit/lie and mainly in bed is proportionate to the amount of time the patient is able to sit up vs need to lie down.

Activity & Extent of Disease

Some, significant, and extensive disease refer to physical and investigative evidence which shows degrees of progression. For example in breast cancer, a local recurrence would imply some disease, one or two metastases in the lung or bone would imply significant disease, whereas multiple metastases in lung, bone, liver, brain, hypercalcemia, or other major complications would be extensive disease.

The extent may also refer to progression of disease despite active treatments. Using the PPS in AIDS, some 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.

The above extent of disease is also judged in context with the ability to maintain one’s work and hobbies or activities. Decline in activity may mean the person still plays golf but reduces from playing 18 holes to 9 holes, or just a par 3, or to backyard putting. People who enjoy walking will gradually reduce the distance covered, although they may continue trying, sometimes even close to death (e.g., trying to walk the halls).

Self-Care

• Occasional assistance means that most of the time patients are able to transfer out of bed, walk, wash, toilet, and eat by their own means, but that on occasion (perhaps once daily or a few times weekly) they require minor assistance.
• Considerable assistance means that regularly every day the patient needs help, usually by one person, to do some of the activities noted above. For example, the person needs help to get to the bathroom but is then able to brush their teeth or wash at least hands and face. Food will often need to be cut into edible sizes but the patient is then able to eat of their own accord.
• Mainly assistance is a further extension of considerable. Using the above example, the patient now needs help getting up but also needs assistance washing their face and shaving, but 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 without help, toilet, or do any self-care. Depending on the clinical situation, the patient may or may not be able to chew and swallow food once prepared and fed to him or her.

Intake

Changes in intake are quite obvious:

• Normal intake refers to the person’s usual eating habits while healthy.
• Reduced means any reduction from that and is highly variable according to the unique individual circumstances.
• Minimal refers to very small amounts, usually pureed or liquid, which are well below nutritional sustenance.

Conscious Level

• Full consciousness implies full alertness and orientation with good cognitive abilities in various domains of thinking, memory, etc.
• Confusion is used to denote presence of either delirium or dementia and is a reduced level of consciousness. It may be mild, moderate, or severe with multiple possible etiologies.
• Drowsiness implies either fatigue, drug side effects, 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; some reflexes may or may not remain. The depth of coma may fluctuate throughout a 24-hour period.

Download the Palliative Performance Scale brochure.

¹ Harrold, Joan, Rickerson, Elizabeth, Carroll, Janet T., McGrath, Jennifer, Morales, Knashawn, Kapo, Jennifer, Casarett, David. Is the Palliative Scale a Useful Predictor of Mortality in a Heterogeneous Hospice Program? Journal of Palliative Medicine. 2005, 43 (3): 503-509.

² Palliative Performance Scale (PPSv2) version 2. Medical Care of the Dying, 4th ed.; 120-121. ©Victoria Hospice Society, 2006.