TVN palliative frailty Algorithm


TVN palliative frailty Algorithm

Project Title

Helping the primary care system identify, plan, and care for seriously ill, frail elderly

Time Period and Funding

2015-7, Technology Evaluation in the Elderly Network (TVN) National Centre of Excellence (NCE), $396,368

Principal Investigators

Robin Urquhart, Fred Burge

Co-investigators and collaborators

Grace Johnston, Nandini Natarajan, Cheryl Tschupruk, Francis Lau, Tara Sampalli, Emily Marshall, Jyoti Kotecha, Doug Manual, Peter Tanuseputro, Bev Lawson, Colleen Cash

Project Staff

Sarah Sabri, Colleen O’Connell


Help primary healthcare providers and systems engage in advance care planning (ACP) for elderly patients who are frail and/or living with a chronic illness that may be life threatening.


  • Develop a validated electronic algorithm to help primary health care providers identify elderly patients who are frail and/or at risk of declining health and dying
  • Investigate how the algorithm can best be adopted and implemented in primary health care
  • Explore the clinical, policy and social implications of this identification
  • Determine the patients’ and families’ needs for ACP and their views and preferences for who should initiate ACP, where it should happen and at what time in the course of their illness


  • Organized strategy to identify elderly patients at risk of dying in the next 12-18 months
  • Information to successfully implement this strategy into primary healthcare practice
  • Information to scale up early identification and ACP in primary healthcare across Canada