How does a healthcare provider coordinate and order palliative care for patients with serious illnesses, such as cancer, heart disease, or respiratory disease?

How Healthcare Providers Coordinate and Order Palliative Care

Healthcare providers should initiate palliative care consultation immediately at the time of diagnosis for patients with serious illnesses such as metastatic cancer, advanced heart failure, or progressive respiratory disease—ideally within 8 weeks of diagnosis—rather than waiting until end-stage disease or when curative options are exhausted. 1, 2

Who Initiates the Palliative Care Referral

The attending physician or primary oncologist bears primary responsibility for coordinating palliative care referrals, but any member of the healthcare team, the patient themselves, or family members can and should initiate the request. 2 The key is that once requested, the attending physician must facilitate the discussion and coordinate the formal consultation. 2

Screening Criteria That Trigger Palliative Care Orders

Primary oncology teams and attending physicians should screen all patients at every visit for the following criteria, and any positive screen mandates a full palliative care assessment: 1

• Uncontrolled physical symptoms (pain, dyspnea, nausea, fatigue) 1
• Moderate to severe emotional distress related to diagnosis or prognosis 1
• Serious comorbid physical, psychiatric, or psychosocial conditions 1
• Life expectancy of 6 months or less 1
• Patient or family concerns about disease course or decision-making 1
• Specific request for palliative care by patient or family 1

For heart failure patients specifically, specialist palliative care consultation is particularly useful for stage D patients being evaluated for advanced therapies, those requiring inotropic or temporary mechanical support, those with uncontrolled symptoms, major medical decisions, or multimorbidity with frailty and cognitive impairment. 1

The Formal Referral Process

Step 1: Inform and Educate

Before ordering the consultation, the oncology or primary team should inform patients and families about the role and benefits of palliative care services, explicitly clarifying that palliative care does NOT mean "giving up" on treatment and can be delivered concurrently with all curative and life-prolonging therapies. 1, 2

Step 2: Order the Consultation

The provider places a formal order or referral to the interdisciplinary palliative care team, which must include at minimum a physician, nurse, social worker, and spiritual counselor. 1 For Medicare-covered LVAD implantation in the United States, inclusion of a palliative care specialist on the team is mandatory for payment. 1

Step 3: Specify the Consultation Setting

Palliative care can be ordered in multiple settings: 2

• Inpatient consultation service (hospital-based palliative care team) 3
• Outpatient palliative care clinic (integrated within oncology or as standalone) 1
• Home-based palliative care 2
• Nursing home or long-term care facility 2

Essential Components the Palliative Care Team Must Address

The palliative care consultation must include standardized assessments and interventions across these domains: 1

• Rapport and relationship building with patient and family caregivers 1
• Symptom assessment and management using validated tools for pain, dyspnea, fatigue, sleep disturbance, mood, nausea, and constipation 1
• Exploration of illness understanding and prognosis education 1
• Clarification of treatment goals, including the relative importance of quality of life versus length of life 1
• Assessment and support of coping needs (provision of dignity therapy) 1
• Assistance with medical decision-making 1
• Coordination with other care providers 1
• Provision of referrals to other services as indicated 1
• Advance care planning, including advance directives, healthcare proxy, and resuscitation preferences 1

Timing Benchmarks for Specific Diseases

Cancer

For newly diagnosed patients with advanced cancer, palliative care involvement should start within 8 weeks of diagnosis of metastatic disease. 1 This timeline is based on landmark evidence showing improved quality of life and survival when palliative care begins early. 1

Heart Failure

Palliative care should be integrated throughout the continuum of heart failure care, starting early in the course of illness, intensifying in end-stage disease, and extending into caregiver bereavement. 1 Discussions about discontinuation of potentially life-sustaining therapies (intravenous inotropes, ICDs, mechanical circulatory support) should be anticipated and discussed at the time of initiation and reassessed with changing medical conditions. 1

Respiratory Disease

For COPD and other progressive respiratory diseases, palliative care should be initiated when patients experience progressive dyspnea, frequent exacerbations, or declining functional status, regardless of disease stage. 2 The disparity in palliative care access for COPD patients compared to lung cancer patients must be actively addressed, as depression and lack of advance care planning create barriers to communication. 1

Coordination with Hospice

Palliative care is NOT synonymous with hospice. 2 Hospice is a subset of palliative care reserved for patients with a prognosis of 6 months or less who choose to forgo disease-directed treatment. 1 In patients with advanced heart failure with expected survival less than 6 months, timely referral to hospice is useful to improve quality of life. 1 The provider must ensure that Medicare, Medicaid, and other insurers' requirements are met: a treating physician and hospice medical director must certify the patient's prognosis. 1

Common Pitfalls to Avoid

Avoid these critical errors when coordinating palliative care: 2, 4

• Delaying consultation until end-of-life: This negatively impacts outcomes; palliative care can begin at diagnosis and be provided concurrently with curative treatments 2, 4
• Failing to complete advance care planning early: This leads to inadequate end-of-life care and treatment inconsistent with patient wishes 4
• Introducing palliative care in a threatening way: Frame it as concurrent delivery with active treatment, not as "giving up" 4
• Inadequate communication about prognosis: Poor communication results in patients receiving more aggressive care than they desire 1
• Equating palliative care with hastening death: Evidence shows palliative care improves quality of life and may extend survival in some cancer patients 2

Documentation Requirements

The provider must ensure complete documentation that is accessible across all care settings, including: 1

• Advance directives (durable power of attorney, living will) 1
• POLST/MOLST forms (more effective than traditional advance directives alone) 5
• Confirmation of patient values and decisions in light of status changes 1
• Preferred location of death 1
• Code status and resuscitation preferences 1

Copies should be distributed to the patient's family, loved ones, and all treating physicians, with mechanisms in place to ensure these preferences are accessible to all healthcare providers. 1