Caregiver Support Form :: Hospice Northwest

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Support for Caregivers & Families
Providing end-of-life
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PPS Level	Ambulation	Activity & Evidence of Disease	Self-Care	Intake	Conscious Level
100%	Full	Normal activity & work No evidence of disease	Full	Normal	Full
90%	Full	Normal activity & work Some evidence of disease	Full	Normal	Full
80%	Full	Normal activity with effort Some evidence of disease	Full	Normal or reduced	Full
70%	Reduced	Unable Normal Job/Work Significant Disease	Full	Normal or reduced	Full
60%	Reduced	Unable hobby / housework Significant Disease	Considerable assistance necessary	Normal or reduced	Full or Confusion
50%	Mainly Sit/Lit	Unable to do any work Extensive disease	Considerable assistance requires	Normal or reduced	Full or Confusion
40%	Mainly in Bed	Unable to do most activity Extensive disease	Mainly assistance	Normal or reduced	Full or Drowsy +/- Confusion
30%	Totally Bed Bound	Unable to do any activity Extensive disease	Total care	Normal or reduced	Full or Drowsy +/- Confusion
20%	Totally Bed Bound	Unable to do any activity Extensive disease	Total care	Minimal to sips	Full or Drowsy +/- Confusion
10%	Totally Bed Bound	Unable to do any activity Extensive disease	Total care	Mouth care only	Drowsy or Coma +/- Confusion
0%	Death

Referral Form – Caregiver Support