What are the criteria for identifying patients in need of palliative care in a primary care setting?

From the Guidelines

Identifying patients who need palliative care in primary care settings requires a systematic approach using specific screening tools and clinical indicators, with the most recent guidelines suggesting referral criteria such as persistent symptoms despite optimal medical therapy, major medical decisions, and multimorbidity, frailty, or cognitive impairment 1.

Key Considerations

• Primary care providers should implement routine screening for all patients with serious illnesses using tools like the Supportive and Palliative Care Indicators Tool (SPICT) or the Surprise Question ("Would you be surprised if this patient died within the next 12 months?") 1.
• Key clinical indicators that warrant palliative care assessment include declining functional status, uncontrolled symptoms (pain, dyspnea, nausea), frequent hospitalizations, weight loss exceeding 10% in six months, and disease progression despite optimal treatment 1.
• When these indicators are present, providers should initiate goals of care conversations, assess symptom burden using validated tools like the Edmonton Symptom Assessment Scale, and establish a care plan addressing physical, psychological, social, and spiritual needs 1.

Integration into Primary Care

• This approach should be integrated into routine primary care workflows, with regular reassessment as the patient's condition changes 1.
• Early identification allows for better symptom management, reduced emergency visits, and improved quality of life by addressing the full spectrum of needs before a crisis occurs 1.
• The primary care provider remains central to coordinating care even when specialist palliative services become involved, ensuring continuity of comprehensive care throughout the illness trajectory 1.

Recent Guidelines

• The most recent guidelines, such as the 2022 AHA/ACC/HFSA guidelines on heart failure, provide a framework for identifying patients who may benefit from palliative care, including those with persistent symptoms, major medical decisions, and multimorbidity, frailty, or cognitive impairment 1.
• These guidelines emphasize the importance of early palliative care integration and provide a set of criteria to identify patients who may benefit from specialty palliative care 1.

From the Research

Criteria for Identifying Patients in Need of Palliative Care

The criteria for identifying patients in need of palliative care in a primary care setting include:

• Patients suffering from symptoms of a life-limiting illness 2
• Patients with advanced medical illness, where palliative care aims to alleviate suffering and improve quality of life 2, 3
• Patients with a prognosis of 6 months or less, where hospice care is appropriate 2, 3
• Patients who would not be surprised if they died in the next 2 years, as determined by "The Surprise Question" 2
• Patients with serious illness, defined as an illness with high risk of mortality that negatively affects quality of life or function, or is burdensome in symptoms, treatments, or caregiver stress 3

Characteristics of Non-Hospice Palliative Care Interventions

Non-hospice palliative care interventions have been categorized into primary, specialty, and hybrid models 4

• Common challenges among these models include limited education of generalists, limited reimbursement, and limited access in certain areas 4
• Increasing palliative care usage has been associated with increased hospice use and appropriate timing of referrals 4

Palliative Care Needs in Neurodegenerative Illness

Patients and families affected by a neurodegenerative illness have significant palliative care needs beginning at the time of diagnosis and extending through end-of-life care and bereavement 5

• Key skills in providing effective palliative care to this population include providing the diagnosis with compassion, setting goals of care, anticipating safety concerns, caregiver assessment, advance care planning, addressing psychosocial concerns, and timely referral to a hospice 5

Early Palliative Care

Early palliative care is associated with increased quality of life, better symptom management, and increased advance care plans for patients with life-limiting chronic illnesses 6

• However, there is uncertainty over what is considered to be "early palliative care", presenting a barrier to evaluating associated outcomes 6