Complexity of patient care needs in palliative care: a scoping review

Abstract

Background: Recognizing the need for palliative care (PC) and referral to PC teams improves patients' quality of life. However, in patients with moderate/severe clinical complexity, early recognition of the need for PC may not correspond to referral to specialized PC services. The definition for clinical complexity is still underexplored, as well as the instruments available to assess complexity. This scoping review aims to gather relevant information on the definition of clinical complexity in PC, as well as on the instruments used to objectively assess complexity.Methods: According to the methodology of a Scoping Review, the keywords: "palliative care", "hospitalization criteria", "complexity criteria", "complexity assessment" and "clinical complexity", were searched in PubMed, Scopus, Cochrane, and b-on databases, during April 2022, for relevant information on the definition and/or approach and/or protocols related to clinical complexity in patients followed in PC, or on the instruments used to assess it, regardless of study design, the language, or year of publication.Results: From the 626 references found, 15 studies were included in the review. According to these studies, complexity may be organized/defined into 3, 4, or 6 domains, generally including the patient, the family, the health system, and the socio-cultural context. Of the 13 instruments mentioned for the objective assessment of complexity, the HexCom, IDC-Pal, and the recent ID-PALL seem to offer the broadest determinations of complexity.Conclusions: Complexity is a dynamic process, which reflects the reality of patients and families, and patients, families, and health professionals' perceptions, and so it must be systematically adjusted to the stage of the disease. The definition of complexity and the development and use of suitable instruments can help to identify, assess, and improve patients' quality of life, while supporting their family across the grieving process.Yet, this may not always be summarized in a quantitative value by easy-to-use instruments, highlighting the role of PC interdisciplinary teams.

Evolution of Complexity of Palliative Care Needs and Patient Profiles according to the PALCOM Scale: Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients

“…Several tools that define and categorise the construct of complexity of PC needs have been described (Hex-Com, Perroca-Scale, AN-SNAP, Hui-Major-Criteria, IDC-Pal, PALCOM). [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46] All these tools include a multidimensional evaluation of the patient with the aim of establishing early referral criteria for multidisciplinary teams specialized in EPC. In some cases, the methodology of development of these scales is based on the consensus of experts regarding the conditions of complexity and their validation in transversal or Delphi studies [32][33][34], and in other cases it is based on prospective observational studies to determine predictive variables of complexity and their external validations (PALCOM scale) [31,46].…”

“…Barthel index ≤60 or Karnofsky index ≤50-60%) Complex systems are characterised by depending on the continuous interaction of multiple variables within an unstable equilibrium that is very sensitive to rapid, and not always predictable, changes from the initial conditions. [37][38][39][40][41][42][43][44][45][46] In accordance with this argument, the analysis of evolutionary instability is essential to understand the model of palliative complexity.…”

“…A recent review of the literature identified 6 models of classification of the complexity of PC needs, aimed at managing referral and shared care with the specialized EPC teams ((Hex-Com, Perroca-Scale, AN-SNAP, Hui-Major-Criteria, IDC-Pal, PALCOM). [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46] The use of these tools allows the complexity of PC needs to be categorized as low, in which basic PC would be indicated (primary or secondary PC) or medium-high, in which care by specialized EPC teams would be systematically indicated (tertiary PC).…”

Validation Study of the PALCOM Scale of Complexity of Palliative Care Needs: A Cohort Study in Advanced Cancer Patients

“…Different models of classification of the complexity of palliative needs have been developed (Hex-Com, Perroca-Scale, AN-SNAP, Hui-Major-Criteria, IDC-Pal, PALCOM) [ 35 , 35 , 37 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ]. Most of these tools are based on the consensus of experts who identified the characteristics considered to be of greatest complexity and their posterior validation in cross-sectional or Delphi studies.…”

Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients

“…The intrinsic difficulty of a targeted referral model, which is easy to accept from a theoretical point of view, is that the categorization of the complexity of PC needs is neither agreed upon nor well-defined. A recent review of the literature identified six models of classification of the complexity of PC needs, aimed at managing referral and shared care with the specialized EPC teams (Hex-Com, Perroca-Scale, AN-SNAP, Hui-Major-Criteria, IDC-Pal, PALCOM) [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46]. The use of these tools allows the complexity of PC needs to be categorized as low, in which basic PC would be indicated (primary or secondary PC) or medium-high, in which care by specialized EPC teams would be systematically indicated (tertiary PC).…”