Timely Palliative Care: Personalizing the Process of Referral

Abstract

Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.

The feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial

“…This was largely reflecting the high number of people already receiving, or needing imminent palliative care at the identified trigger, thus rendering them ineligible in the clinical trial context. Despite this, it was interesting that our survival data on the participants in these cohorts, albeit small numbers, was broadly consistent with the literature recommending palliative care input for those with a life expectancy of 6-24 months (24,41). Going forward in clinical practice and outside of a trial setting, this may suggest that these trigger points as outlined are not unreasonable as a 'minimum standard' to prompt the initiation of palliative care if not already in place.…”

“…Barriers to palliative care referral have been identified, including: concerns about difficulty of referral, fear of destroying patient hope associated with perceptions of palliative care ( 21 ) and uncertainty over the ‘best time’ to refer ( 22 ). The literature has variably defined ‘early’, including to mean at least 3-4 months prior to death to confer benefits ( 8 ), within 3 months of advanced cancer diagnosis for patients with a life expectancy of 1 year or less ( 23 ), and ideally engagement with palliative care spanning 6-18 months before death ( 24 ).…”

“…Similarly, standardisation would reduce variations and inequities in access to care. Such a standardised time of introduction should be based on evidence and be tailored to the disease characteristics and likely history, allowing for consideration of balancing the potential for maximal outcome benefit versus managing the volume of early consultations and resourcing implications ( 23 , 24 ). Yet to date, few studies have explored the role of systematic triggers for timely palliative care referral ( 26 – 29 ).…”

Longitudinal symptoms and temporal trends in palliative care, palliative radiotherapy, and anti-cancer treatment near end of life among patients with metastatic cancer

“…We defined earlier specialty PC as occurring in quartiles 1-3 and later specialty PC as occurring in quartile 4. Previous studies support time-based criteria for early integration of specialty PC, including within 2-3 months of diagnosis of advanced or incurable cancer (3,22,23). The primary outcomes included distributions of specialty PC, palliative RT, admissions, hospice referral, and symptoms over relative survival time.…”

The Paradigm Shift from End of Life to Pre-Emptive Palliative Care in Patients with Cancer

“…Rather than generic “early palliative care”, a better term could be “timely palliative care”, which is personalized care based on patients’ needs and delivered at the optimal time and setting [ 13 ]. This all-in-one model has been spontaneously growing in our center, possibly due to a favorable context, long-term tradition, a certain scientific reputation, and relationships between leaders and local administration, regardless of the regional health care system, which instead still offers a delayed network of palliative care invariably based on hospice and home care.…”