Frailty, thy name is Palliative!
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* Vincent Maida
* Melissa Devlin

Kahlon and colleagues have published important data that relates frailty with 30-day outcomes after discharge from hospital, such as readmission to hospital and death.1 We are concerned that an important conclusion may have been missed.

Frailty remains a vague and subjective construct that represents an amalgam of curable and incurable illnesses. Furthermore, increasing levels of frailty combined with advancing age translates into decreased life expectancy. A common attitude within health care is that frailty is generally reversible and curable. Thus, is the word “frailty” being used as a euphemism? Are the patients in this study simply frail or are they terminally ill? The documentation of frailty, or worsening of frailty scores, should trigger the need for patient-centred discussions about diagnosis, natural history of disease, prognosis, treatment options and goals of care.2 This process may trigger the need for a palliative care consultation.

Patients labelled as frail are at high risk of readmission to hospital because they are often given unrealistic expectations for improvement and rehabilitation. The reason for readmission among “frail” patients may be related to the lack of the aforementioned discussion. Perhaps, had it occurred, and if patients had accepted conservative palliative modes of care, such patients would be admitted to community-based hospices or palliative home programs or care units instead of being readmitted to general hospitals.

The domain of palliative care uses the Palliative Performance Scale (PPS) to monitor illness trajectory.3 Systematic reviews have shown that PPS is the most robust indicator for life expectancy estimates for incurable advanced illness.4 There is a need to study the correlation between frailty tools and performance status tools. Perhaps a composite score combining frailty scores and PPS may provide a way to identify early patients who should be referred for palliative care.

## References

1.  Kahlon S, Pederson J, Majumdar SR, et al. Association between frailty and 30-day outcomes after discharge from hospital. CMAJ 2015;187:799–804.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTg3LzExLzc5OSI7czo0OiJhdG9tIjtzOjI0OiIvY21hai8xODcvMTcvMTMxMi4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Picker Institute: Patient-centred care 2015: scenarios, vision, goals & next steps. 2004. Available: [www.pickerinstitute.org](http://www.pickerinstitute.org) (accessed 2015 Aug. 21).
    
    

3.  Anderson F, Downing GM, Hill J, et al. Palliative Performance Scale (PPS): a new tool. J Palliat Care 1996;12:5–11.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=8857241&link_type=MED&atom=%2Fcmaj%2F187%2F17%2F1312.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1996UG06700002&link_type=ISI) 

4.  Downing GM, Lesperance M, Lau F, et al. Survival implications of sudden functional decline as a sentinel event using the Palliative Performance Scale. J Palliat Med 2010;13:549–57.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1089/jpm.2009.0299&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=20377498&link_type=MED&atom=%2Fcmaj%2F187%2F17%2F1312.2.atom)