Which of the following patients is least likely to benefit from a palliative‑medicine consultation: a 93‑year‑old man with newly diagnosed acute myeloid leukemia (AML) considering chemotherapy; a 63‑year‑old man with ischemic cardiomyopathy (ICM) and severe dyspnea despite maximal medical therapy who wants to continue all disease‑directed interventions; a 54‑year‑old man with renal cell carcinoma (RCC) experiencing severe cancer‑related pain while on oral methadone and now NPO; or a 76‑year‑old woman hospitalized for her fourth chronic obstructive pulmonary disease (COPD) exacerbation this year who expresses a wish for hospice?

Which Patient May Benefit Least from Palliative Medicine Consultation?

The 76-year-old woman hospitalized for her fourth COPD exacerbation this year who states that she wants hospice would benefit least from a palliative medicine consultation because she has already clearly articulated her goals of care and is ready for hospice transition, which provides comprehensive palliative services without requiring an additional specialty palliative care consultation. 1

Rationale for Each Patient

93-Year-Old Male with Newly Diagnosed AML Considering Chemotherapy (HIGH BENEFIT)

• Patients with AML have significant palliative care needs from diagnosis onward, regardless of treatment intensity chosen 1, 2
• The 2024 ASCO Guideline explicitly recommends that patients with hematologic malignancies who experience uncontrolled symptoms, psychosocial needs, or quality of life concerns should be offered palliative care from the time of diagnosis throughout the trajectory of illness 1
• This 93-year-old patient faces complex decision-making about intensive chemotherapy versus lower-intensity therapy versus best supportive care, which requires early palliative care integration to clarify goals, manage symptoms, and support advance care planning 1, 2
• Recent evidence demonstrates that early integrated inpatient palliative care for patients with AML receiving chemotherapy improves quality of life, psychological outcomes (depression, anxiety, PTSD), and advance care planning participation 1, 3
• Older patients with AML benefit from concurrent palliative care at diagnosis to improve patient survival and quality of life, whether receiving intensive or low-intensity therapy 4

63-Year-Old Male with ICM and Severe Dyspnea Despite Maximal Medical Therapy (HIGH BENEFIT)

• This patient has refractory nonpain symptoms (severe dyspnea) and a high symptom burden despite maximal medical therapy, which are explicit indications for palliative care consultation 1
• The NCCN Palliative Care Guidelines specifically recommend consultation for patients with refractory symptoms or high symptom burden 1
• Palliative care specialists can optimize dyspnea management through opioids (morphine 2.5-10 mg PO every 2 hours PRN), benzodiazepines for anxiety-associated dyspnea, and non-pharmacologic interventions 5
• Despite his desire to continue disease-directed interventions, palliative care consultation is appropriate and beneficial alongside continued aggressive treatment to address symptom burden and support goals of care discussions 1

54-Year-Old Male with RCC and Severe Cancer-Associated Pain, Now NPO (HIGH BENEFIT)

• This patient has severe cancer-associated pain requiring complex medication management (oral methadone) and is now NPO, creating an urgent need for route conversion and pain control 1
• The NCCN Guidelines recommend palliative care consultation for patients at high risk for poor pain control and those with history of allergies or adverse effects to multiple palliative interventions 1
• Opioid rotation and route conversion require specialty expertise, particularly when transitioning from oral methadone (long half-life, complex pharmacokinetics) to parenteral or transdermal routes 5
• This represents a complex pain management scenario requiring immediate specialist input to prevent uncontrolled pain and withdrawal 1, 5

76-Year-Old Female with Fourth COPD Exacerbation Who Wants Hospice (LEAST BENEFIT)

• This patient has already clearly articulated her goals of care (hospice) and is ready for transition, which is the primary work that palliative care consultation would accomplish 1
• The NCCN Guidelines identify that goals and expectations that might be better met by the hospice model of palliative care should be identified, and this patient has self-identified this preference 1
• Hospice provides comprehensive palliative services including symptom management, psychosocial support, spiritual care, and bereavement services, making an additional specialty palliative care consultation redundant 1, 5
• The appropriate intervention is direct hospice referral rather than palliative care consultation, as she meets hospice eligibility criteria (fourth exacerbation this year, progressive disease) and has expressed this preference 1

Key Clinical Distinction

The critical difference is that the COPD patient has already completed the goals-of-care clarification process and is ready for hospice transition, whereas the other three patients require active palliative care intervention for complex symptom management, treatment decision-making support, or both 1. The AML, heart failure, and cancer pain patients all have ongoing palliative care needs that cannot be deferred to hospice because they are either pursuing disease-directed therapy or require immediate complex symptom management 1.