From the Guidelines
Patients with advanced cancer or other serious illnesses should be referred to palliative care early in the course of their disease, alongside active treatment, to improve symptom management, quality of life, and potentially extend survival. This approach is supported by the most recent and highest quality study, which recommends referring patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer 1.
Indications for Palliative Care Referral
The indications for referring a patient to palliative care include:
- Advanced cancer, such as solid tumors or hematologic malignancies
- Significant symptom burden, such as pain, dyspnea, nausea, fatigue, or psychological distress
- Declining functional status
- Uncontrolled symptoms despite standard treatments
- Need for assistance with difficult medical decisions or advance care planning
- Significant caregiver burden
Benefits of Early Palliative Care Referral
Early referral to palliative care can lead to:
- Improved symptom management
- Better quality of life
- Reduced hospitalizations
- Potential extension of survival
- Enhanced patient and family satisfaction with care
Essential Components of Palliative Care
Palliative care should include:
- Rapport and relationship building with patient and family caregivers
- Symptom, distress, and functional status management
- Exploration of understanding and education about illness and prognosis
- Clarification of treatment goals
- Assessment and support of coping and spiritual needs
- Assistance with medical decision making
- Coordination with other care providers
- Provision of referrals to other care providers as indicated 1.
Timing of Palliative Care Referral
The optimal timing for palliative care referral is early in the disease course, ideally within 8 weeks of diagnosis for newly diagnosed patients with advanced cancer 1. However, referral can occur at any point in the disease trajectory when patients experience significant symptom burden, declining functional status, or need assistance with medical decision making.
Palliative Care Delivery
Palliative care should be delivered through interdisciplinary palliative care teams, with consultation available in both outpatient and inpatient settings 1. This team-based approach ensures comprehensive care that addresses the physical, emotional, social, and spiritual needs of patients and their families.
From the Research
Indications for Referring a Patient to Palliative Care
The decision to refer a patient to palliative care is based on various factors, including the patient's diagnosis, symptoms, and quality of life. Some key indications for referral include:
- Serious illness, such as cancer, heart failure, or chronic obstructive pulmonary disease (COPD) 2, 3, 4, 5, 6
- Presence of physical or emotional symptoms, such as pain, shortness of breath, nausea, or fatigue 2, 3, 4, 6
- Advanced disease stage, such as New York Heart Association functional class ≥III or IV 6
- Prognosis of ≤1 year 6
- Hospital utilization, such as frequent hospital admissions 6
- Need for symptom management or support with daily activities 4, 5
- Patient or family request for palliative care 2, 5
Disease-Specific Indications
Different diseases have different indications for palliative care referral. For example:
- Cancer: earlier primary cancer diagnosis, referral for pain and symptom management 4
- Heart failure: cardiac stage, hospital utilization, prognosis, advanced cardiac therapies 6
- COPD: slower and more varied trajectory of illness, need for functionality and hospital admission support 3
- Chronic obstructive lung disease, heart failure, or dementia: experienced needs within different domains of palliative care at different stages of the illness trajectory 5
Timing of Referral
The timing of referral to palliative care is also an important consideration. Early referral, defined as >12 months before death, is associated with better symptom management and quality of life 4. However, referrals are often late, with 69% of patients referred to palliative care <6 months before death 4.