What can the Clinical Frailty Scale tell us about planning for death?
An article written by Dr Robin Blythe and Prof. Adrian Barnett
Many clinicians have probably come across the Clinical Frailty Scale during their practice. It is a validated and commonly-used tool that helps differentiate older people on a scale from 1 (very fit) to 9 (terminally ill). In some cases, it may also be used as an indicator for whether to refer older patients to alternative care pathways, including using their score to decide whether to initiate end-of-life care discussions.
In our recently published study exploring how well the Scale predicts death within 90 days among frail older people, we argue that this should be done very cautiously. [1] The Scale may not be very useful for deciding who should, or should not, receive treatment because it is not really able to tell us whether individual older persons are at a higher risk of dying. In some cases, it might actually paint an unrealistic picture of someone’s prognosis, suggesting some older adults are healthier than they really are.
This can lead us to avoiding discussions about the end-of-life until it is imminent. Patients and their families may feel unprepared for death, and relying on tools to decide when to initiate these discussions may mean that older persons lose their chance to die with dignity. Yet, this doesn’t mean the Scale is not useful. On the contrary, by using it to remind clinicians that frailty is a major component of end-of-life care planning, we can centre these discussions early, avoiding unwanted treatments and improving quality of care.
If the Clinical Frailty Scale is to be used in practice, our study has several recommendations that can help it to facilitate more appropriate care.
First, we argue that the Scale should not be the only factor in deciding whether to initiate treatment or end-of-life care discussions. For example, if a hypothetical new care pathway was developed to identify patients at risk of receiving non-beneficial treatment, relying on the Clinical Frailty Scale alone is unlikely to lead to more appropriate care decisions due to a lack of accuracy.
Second, we argue that uncertainty about an older person’s risk of dying is not sufficient to delay talking about the end of life. Guidelines in cancer state that end-of-life discussions must happen with patients in the last 12 months of life, yet, many models designed to predict survival are inaccurate. Oncologists initiate end-of-life care discussions regardless of this uncertainty.
Finally, we emphasise that, regardless of accuracy, decision aides like the Clinical Frailty Scale are just guides. They are useful to help us consider what is important for decision-making, but they are designed to augment, not replace, our judgement. This applies not just to the Scale, but to all decision support tools, including those created with artificial intelligence. Clinicians must be very careful about delegating their decision-making when it can lead to poor outcomes.
The Clinical Frailty Scale can be a good rule of thumb for clinicians to assess frailty in their older patients. It is very simple to use, which is a real benefit over tools requiring lots of mental calculations and many data sources. However, it should be interpreted cautiously, especially when it is used for deciding who should receive treatment. Uncertainty about the exact timing of death should not be a barrier to planning for the end-of-life.
References:
-
Blythe R, White NM, Brown C, Hillman K, Barnett AG. Validation of the clinical frailty scale for predicting 90-day mortality in hospitalised older adults screened as at risk of nearing the end of life in Queensland, Australia: A multisite observational study. BMJ Open. 2025;15(11):e108419.
Authors
Dr Robin Blythe
Health economist, Programme in Health Services Research and Population Health
Duke-NUS Medical School, Singapore
Prof. Adrian Barnett
Statistician, Australian Centre for Health Services Innovation
Queensland University of Technology