title: Development of a tool for defining and identifying the dying patient in hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL).
abstract: OBJECTIVE
  To develop a screening tool to identify elderly patients at the end of life and quantify the risk of death in hospital or soon after discharge for to minimise prognostic uncertainty and avoid potentially harmful and futile treatments.
  
  
  METHODS
  Narrative literature review of definitions, tools and measurements that could be combined into a screening tool based on routinely available or obtainable data at the point of care to identify elderly patients who are unavoidably dying at the time of admission or at risk of dying during hospitalisation.
  
  
  METHODS
  Variables and thresholds proposed for the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL screening tool) were adopted from existing scales and published research findings showing association with either in-hospital, 30-day or 3-month mortality.
  
  
  RESULTS
  Eighteen predictor instruments and their variants were examined. The final items for the new CriSTAL screening tool included: age ≥65; meeting ≥2 deterioration criteria; an index of frailty with ≥2 criteria; early warning score >4; presence of ≥1 selected comorbidities; nursing home placement; evidence of cognitive impairment; prior emergency hospitalisation or intensive care unit readmission in the past year; abnormal ECG; and proteinuria.
  
  
  CONCLUSIONS
  An unambiguous checklist may assist clinicians in reducing uncertainty patients who are likely to die within the next 3 months and help initiate transparent conversations with families and patients about end-of-life care. Retrospective chart review and prospective validation will be undertaken to optimise the number of prognostic items for easy administration and enhanced generalisability. Development of an evidence-based tool for defining and identifying the dying patient in hospital: CriSTAL.
authors.affiliation: The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Kensington, NSW 2052, Australia.
authors.forename: Magnolia
authors.initials: M
authors.lastname: Cardona-Morrell
authors.affiliation: The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales & Liverpool Hospital, Liverpool BC 1871, New South Wales, Australia.
authors.forename: Ken
authors.initials: K
authors.lastname: Hillman
mesh_terms: D000368:Aged; D006305:Health Status Indicators; D006801:Humans; D007297:Inpatients; D011379:Prognosis; D019452:Terminally Ill; D014218:Triage / Q000379:methods*; D035501:Uncertainty
keywords: Clinical assessment; Clinical decisions; Communication; Prognosis