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Table 1 Palliative and Therapeutic Harmonization (PATH) Approach

From: Evaluation of an initiative to improve advance care planning for a home-based primary care service

UNDERSTAND

Understand health status through comprehensive geriatric assessment, including cognition (stage of dementia), mobility, function, nutrition, social situation, medical illnesses, medications, and trajectory.

COMMUNICATE

Exchange of information. Provide detailed information to patients and/or family. Describe each illness and its trajectory; dementia and its stages; frailty stage; and risks associated with frailty.

EMPOWER

Empower patient and/or family to make informed decisions, including what to do during a health crisis (i.e., an acute decline in health status). Engage patient and/or family-member in directed decision making.

RESPOND

Respond to the health crisis, when it occurs, applying knowledge of frailty stage and advance care plans.