Background     Accurate prognostic information is vital for patients, families, and clinicians. This Fast Fact reviews the Palliative Prognostic Score (PaP); see Fast Fact #125 for information on the Palliative Performance Scale (PPS) and Fast Fact #444 for information on the Palliative Prognostic Index (PPI). The PaP uses the Karnofsky Performance Score (KPS) (see Fast Fact #416) and five other criteria to generate a numerical score from 0 to 17.5 with specific cutoff values to assign patients to three risk groups according to a 30-day survival probability. Unlike many other validated prognostic scales, a significant scoring weight is given to the treating clinician’s clinical prediction of survival (CPS) or “gestalt” prediction. Also, the PaP requires a full blood count for calculation, something which may not always be performed in terminally ill patients with comfort care goals (especially home and inpatient hospice settings).  

Validation and use of the PaP     The PaP has been validated in large prospective studies in adult and pediatric oncology settings, as well as patients in inpatient hospices, inpatient palliative care units, and patients seen by palliative care consult teams. It has been shown to be reliable in various non-cancer diagnoses, but large-scale validation studies have not been published.

Variant of the PaP including delirium (D-PaP)    Since delirium has been shown to be a significant prognostic contributor, the D-PaP was developed to incorporate the clinical presence of delirium. Patients receive 2 extra points if a clinician determines that delirium is present utilizing the CAM algorithm. The maximum score is 19.5 instead of 17.5. In a retrospective analysis of terminally ill cancer patients, the D-PaP performed slightly better than the PaP. 

Variant of the PaP omitting CPS (PaP without CPS)   Since CPS is by its nature a subjective assessment, the PaP without CPS was created which includes only the sum of the scores of the objective variables of PaP.  The maximum score is 9 not 17.5. 

Comparative efficacy of the PaP    There are a few retrospective and prospective studies comparing the PaP to other prognostic scoring systems (PPI, PPS, D-PaP, PaP without CPS) and even fewer comparing PaP with clinician predication of survival (CPS) alone.  These studies suggest that the PPI, D-PaP, and PaP all identify classes of patients with different survival probabilities with good accuracy. The PaP and D-PaP may be slightly more accurate among cancer patients and they may be more accurate than PaP without CPS or the CPS alone. However, larger studies are needed to validate these findings. Also it is worth noting that the PaP only calculates a probability of a 30-day survival in patents with terminal illness; many patients and families want a temporal prediction of how long they may have to live.   

References 

1. Glare P, Eychmueller S, Virik K. The use of the palliative prognostic score in patients with diagnoses other than cancer. J Pain Symp Manage. 2003; 26(4):883-885.  
2. Glare P, Virik K. Independent validation of Palliative Prognostic Score in terminally ill patients referred to a hospital-based palliative medicine consultation service. J Pain Symp Manage. 2001; 22(5):891–898.  
3. Maltoni M, Nanni O, Pirovano M, et al. Successful validation of the palliative prognostic score in terminally ill cancer patients. J Pain Symp Manage. 1999; 17(4):240-247. 
4. Pirovano M, Maltoni M, Nanni O. A new Palliative Prognostic Score: a first step for the staging of terminally ill Cancer patients. J Pain Symp Manage. 1999; 17(4):231-239. 
5. Scarpi E, Maltoni M, et al.  Survival prediction for terminally ill cancer patients: revision of the Palliative Prognosis Score with incorporation of delirium.  The Oncologist 2011;16:1793-99. 
6. Maltoni M, Scarpi E, et al.  Propsective comparison of prognostic scores in palliative care cancer populations. The Oncologist 2012; 17:446-54. 
7. Sonoda H, Yamaguchi T, et al.  American Journal of Hospice and Palliative Medicine 2014;31: 730-4. 
8. Baba M, Maeda I, et al.  Survival predication for advanced cancer patients in the real world: a comparison of the Palliative Prognostic Score, Delirium-Palliative Prognostic Score, Palliative Prognostic Index and modified Prognosis in Palliative Care Study predictor model.  European Journal of Cancer 2015; 51: 1618-29. 
9. Hui D, Park M, Liu D, et al. Clinician prediction of survival versus the palliative prognostic score: which approach is more accurate? European Journal of Cancer 2016; 64:89-95. 
10. Yoon S-J, Suh S-Y, Hui D, et al. Accuracy of the Palliative Prognostic Score with or without clinicians’ prediction of survival with far advanced cancer. JPSM 2020; 61(6):1180-7. 

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in October 2004. 2nd Edition in April 2009; 3rd Edition in July 2015; 4th Edition in February 2024 by Sean Marks MD. 
Conflicts of Interest: None to report.