Why Aisha is on the list
- Record review
- Review recommended
- Conditions recorded
- CKD, Heart failure, Hypertension
- Care planning
- No advance care plan
- Not on the palliative care register in this record source
1 indicator present in the record
Heart failure on the problem list, active, recorded 14 Feb 2026 (SIM-PROBLEM-3). NYHA class is not recorded in this record source.
Shaped after SPICT heart and vascular indicator, adapted: NYHA class is not present in this record source REC_HEART
Recorded 14 Feb 2026
Screening
No screening has been run for this patient.
Record review
The record supports a prompt clinical review for a goals-of-care conversation.
Prompt human review for a priorities-and-future-care conversation is supported, while urgent assessment of potentially reversible neurological symptoms remains the immediate clinical priority. The snapshot documents age 95, active heart failure and CKD, recent episodes of word-finding difficulty with increasing drowsiness for which urgent assessment was advised, and rising urea/creatinine. It does not document function, residence, patient wishes, decision-making capacity, family wishes, an advance care plan, DNACPR/ReSPECT documentation, or active palliative care; these must be established by the human team rather than assumed.
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What the record shows
Serious multimorbidity in advanced age
Age alone is not determinative, but age 95 together with documented active heart failure and CKD supports timely clinician-led review of priorities, acceptable treatments, and contingency planning.
1 source in the record
- Eligible14 Feb 2026
Demographics record ageAtIndex 95, and the longitudinal GP record lists heart failure as active from 2026-02-14 and CKD as active from 2026-05-15.
Recent neurological change requiring urgent assessment
Two episodes of word-finding difficulty and increasing drowsiness may reflect an acute, potentially treatable problem; this requires urgent clinical assessment and also creates a need to clarify preferences once clinically appropriate.
1 source in the record
- Eligible19 Aug 2026
GP encounter states that family described two episodes of word-finding difficulty and increasing drowsiness and that urgent assessment was advised rather than routine follow-up.
Renal markers increased over the available trajectory
The rise warrants clinical interpretation in context and adds uncertainty about current physiological reserve; it does not by itself establish irreversible decline.
2 sources in the record
- Eligible17 Jun 2026
Renal monitoring report records urea 8.4 mmol/L and creatinine 109 µmol/L, with continued monitoring during blood-pressure review.
- Eligible11 Sept 2026
Latest U&E panel in the snapshot records urea 9.7 mmol/L and creatinine 118 µmol/L, both above their stated reference highs.
What they and their family want
- Telephone is recorded as the patient's administrative contact preference.
- The patient's understanding, priorities, preferred place of care, acceptable treatment burden, and willingness to discuss future care are unknown.
- Decision-making capacity for this discussion is not documented and should be assessed at the time, particularly in light of reported drowsiness and language difficulty.
- A family member reported symptoms, but identity, relationship, availability, authority, and wishes are unknown.
- The existence of a health and welfare attorney, ADRT, DNACPR/ReSPECT form, or other legal/care-planning record is unknown beyond this snapshot.
1 source in the record
- Eligible
Repeated administrative observations record telephone preference; a neurological-symptom encounter refers only to 'family'; no patient/family wishes, capacity assessment, named representative, or legal planning document is included.
Care at present
Unknown; no residence or current care setting is documented in the eligible snapshot.
Unknown; activities of daily living, mobility, cognition at baseline, frailty, falls, and change from baseline are not documented.
- GP-led long-term-condition contacts and renal/blood-pressure monitoring are documented.
- Urgent assessment was advised after reported transient language difficulty and increasing drowsiness; completion and outcome are not documented.
- An unidentified family member reported neurological symptoms; no ongoing caring role or availability is documented.
- Current location and residence
- Mobility, daily function, frailty, cognition, nutrition, and symptom burden
- Medication reconciliation and adherence
- Whether urgent neurological assessment occurred and its findings
- Named family/carer contacts and support capacity
- Current heart-failure and CKD severity, treatment, and responsible clinicians
1 source in the record
- Eligible
The record documents GP monitoring and urgent-assessment advice but has no structured residence, functional, mobility, frailty, carer, or completed urgent-assessment information; the EHR medication array is empty.
Clinical decision support only. A named clinician decides. Generated 12 Sept 2026, committed for the demonstration; wording adjusted to Cairn's language rules where the review used terms Cairn avoids.