Who are candidates for palliative care?

Candidates for Palliative Care

Any patient with a serious chronic or life-limiting illness—including cancer, advanced organ failure, progressive neurologic disease, or critical illness—should receive palliative care based on symptom burden and needs assessment rather than prognosis alone, starting at diagnosis and continuing concurrently with disease-directed treatments. 1

Core Eligibility Principles

Palliative care is appropriate for patients across the disease spectrum, not just at end of life. The fundamental shift is from prognosis-based referral to needs-based assessment. 1

Key candidates include:

• Patients with progressive chronic diseases such as COPD, heart failure, cirrhosis, or chronic kidney disease at any stage when symptomatic 1
• All cancer patients with metastatic disease (stage IV), particularly lung cancer, pancreatic cancer, and glioblastoma multiforme, ideally beginning at diagnosis 1
• Neurologic disease patients including those with ALS, advanced dementia, Parkinson's disease, stroke with major deficits, or brain tumors 1, 2
• Critically ill patients in ICUs with respiratory failure or multiorgan dysfunction 1
• Pediatric patients with life-threatening congenital, neuromuscular, metabolic, immunologic, or neurologic diseases 1

Specific Screening Triggers

The primary oncology or medical team should screen patients at every visit for these indicators 1:

Immediate Palliative Care Triggers

• Uncontrolled physical symptoms (pain, dyspnea, nausea, fatigue) 1
• Moderate to severe distress related to diagnosis and therapy 1
• Serious comorbid conditions (physical, psychiatric, or psychosocial) 1
• Life expectancy ≤6 months based on clinical indicators 1
• Patient or family request for palliative care services 1
• Concerns about disease course or decision-making 1

Clinical Indicators of Limited Prognosis

For patients in their last 6 months, specific markers include 1:

• Performance status decline: ECOG ≥3 or Karnofsky ≤50 1
• Metabolic complications: Persistent hypercalcemia 1
• Neurologic complications: CNS metastases, delirium, spinal cord compression 1
• Structural complications: Superior vena cava syndrome, malignant effusions 1
• Organ failure: Liver failure, kidney failure, cachexia 1

Disease-Specific Candidates

Stroke patients who are candidates include those with massive hemispheric or brainstem strokes, particularly elderly patients, where early palliative care discussions ensure prior advance directives are respected 1

Cirrhosis patients should receive palliative care principles regardless of transplant candidacy, with assessment based on needs rather than prognosis, tailored to compensated versus decompensated disease stage 1

Neurologic disease patients benefit from early palliative care initiation due to progressive functional decline, communication barriers (dysarthria, aphasia), and cognitive impairment that threatens decision-making capacity 3, 2

Timing of Initiation

The critical concept is that palliative care should begin when curative/restorative care begins, continue while disease-directed treatments proceed, and extend through withdrawal of life-prolonging treatments and into family bereavement. 1

This concurrent model replaces the outdated sequential approach where palliative care only started after curative treatments ended. 1

Specific Timing Recommendations

• At diagnosis for patients with limited expected survival (metastatic lung, pancreatic cancer, glioblastoma) 1
• At sentinel events: hospital/ICU admission, before life-supporting therapies, before surgery, new cirrhosis complications, transplant eligibility determination 1
• When symptomatic during any progressive or chronic respiratory disease or critical illness 1
• Early in disease course for neurologic conditions to enable communication while patient retains decision-making capacity 3, 2

Consultation Triggers for Specialty Palliative Care

While primary teams should provide basic palliative care principles, specialty palliative care consultation is indicated for 1:

Complex Clinical Situations

• Refractory symptoms or high symptom burden despite primary team interventions 1
• Limited treatment options requiring goals-of-care discussions 1
• History of allergies or adverse effects to multiple palliative interventions 1
• Complicated ICU admissions 1
• High distress scores (≥4 on screening tools) 1
• Cognitive impairment affecting decision-making 1
• Communication barriers 1

Psychosocial Complexity

• Requests for hastened death 1
• Inability to engage in advance care planning 1
• Family discord or intensely dependent relationships 1
• Inadequate social support or caregiver limitations 1
• Spiritual or existential distress 1
• Multiple unresolved losses 1

Common Pitfalls to Avoid

The most critical error is waiting until the last days of life to initiate palliative care. Many physicians mistakenly believe palliative care equals hospice or end-of-life care only, leading to delayed referrals and missed opportunities for symptom management and advance care planning. 4

Prognostic uncertainty should not delay referral. The "surprise question" ("Would I be surprised if this patient died in the next year?") can help identify appropriate candidates when formal prognostic criteria are unclear. 4

Do not restrict palliative care to cancer patients. Physicians are often unaware of eligibility criteria for non-cancer illnesses like COPD, heart failure, and neurologic diseases, resulting in inequitable access. 4

Avoid the misconception that palliative care requires stopping disease-directed treatment. The concurrent care model allows patients to receive chemotherapy, dialysis, or other treatments while simultaneously addressing symptoms and psychosocial needs. 1