What is the Palliative Performance Scale?

What is the Palliative Performance Scale

The Palliative Performance Scale (PPS) is a validated 11-level functional assessment tool (ranging from 0% to 100% in 10% increments) that evaluates five domains—ambulation, activity level/evidence of disease, self-care, oral intake, and level of consciousness—to measure performance status and predict prognosis in patients with serious illness. 1, 2

Structure and Scoring Domains

The PPS expands beyond the Karnofsky Performance Status by incorporating five specific assessment domains: 1

• Ambulation: Ability to move around independently
• Activity level and evidence of disease: Work capacity and disease burden
• Self-care: Ability to perform activities of daily living
• Oral intake: Nutritional status and ability to eat/drink
• Level of consciousness: Mental status from full alertness to drowsiness/coma

Each patient receives a score from 0% (death) to 100% (fully ambulatory, normal activity) in 10% increments, with lower scores indicating worse functional status and poorer prognosis. 2, 3

Clinical Applications and Uses

PPS serves multiple critical functions in palliative care practice: 3

• Prognostication: Lower PPS scores correlate with shorter survival times, though modern estimates show substantially longer survival (2.3- to 11.7-fold) than historical data commonly cited by clinicians 4
• Treatment decision-making: Patients with PPS ≤50% (equivalent to KPS <60%) should receive palliative/best supportive care only without systemic therapy due to severely compromised functional status 1
• Care planning: Determines appropriate level of care based on functional status 1
• Communication tool: Facilitates discussions between palliative care workers about patient status 3
• Resource allocation: Helps analyze home nursing care workload and profile hospice admissions 2
• Disease monitoring: Tracks functional decline over time, with falling PPS scores indicating increased mortality risk 5

Prognostic Performance by Setting

The PPS demonstrates different predictive accuracy depending on care setting: 4

• Inpatient setting: Good discriminative ability (integrated time-dependent AUC 0.74) for predicting survival
• Outpatient setting: Lower discriminative ability (integrated AUC 0.67)
• Short-term prediction: Better at predicting 1-month survival than longer-term outcomes
• Cancer vs. non-cancer: Mortality rates are higher for cancer patients than other serious illnesses at most PPS levels

Reliability and Validity

The PPS has demonstrated strong psychometric properties across multiple studies: 3, 6

• Inter-rater reliability: Intraclass correlation coefficients ranging from 0.931 to 0.964, with mean Cohen's kappa of 0.67-0.71 3
• Consistency: Excellent correlation between different rater types (oncologists, radiation therapists, research assistants) with correlation coefficients of 0.69-0.86 6
• Content validity: Palliative care experts universally agree PPS is a valuable clinical assessment tool, with many incorporating it as practice standard 3

Specific Prognostic Thresholds

Key PPS cutoffs trigger specific clinical actions: 1, 2

• PPS ≤50%: Initiate immediate goals-of-care discussions, provide aggressive symptom management, and avoid systemic therapy 1
• PPS 40-70%: Most common range for home palliative care patients (73% in original validation) 2
• PPS 20-50%: Typical range for hospice unit admissions (83% of admissions) 2
• PPS 10-30%: Triggers discussions about hospice care 1

Integration with Other Prognostic Tools

The PPS can be combined with laboratory and clinical parameters for enhanced prognostic accuracy: 1

• Palliative Prognostic Score (PaP): Incorporates KPS/PPS with dyspnea (+1 point), anorexia (+1.5 points), leukocytosis (0-1.5 points), and lymphocytopenia (0-2.5 points) to predict 30-day survival
• Laboratory augmentation: Complete blood count and C-reactive protein may refine survival probability in patients with PPS 40-50% 1

Limitations and Caveats

Important constraints to recognize when using PPS: 5, 4

• Disease-specific performance: May not identify subtle functional changes in patients with advanced dementia or frailty 5
• Setting-specific survival: Median survival figures differ substantially across care settings and populations; caution is needed when generalizing survival data 5
• Updated prognostic estimates: Historical survival estimates are significantly shorter than modern practice patterns; clinicians should use updated calculators specific to setting and diagnosis 4
• Non-malignant disease: Further research needed to validate PPS performance in patients with non-cancer serious illnesses 5

Practical Implementation

The PPS is quick and easy to use in clinical practice, requiring minimal training for healthcare professionals across disciplines. 5, 3 Most clinicians find it helps recognize disease progression in cancer patients and serves as an effective communication tool between team members. 5