Identifying patients who could benefit from palliative care is crucial for enhancing their quality of life and aligning treatment with their goals. Palliative care is appropriate for any patient facing a serious illness, regardless of their prognosis. A palliative care consultation offers invaluable support in managing complex symptoms, addressing emotional and spiritual distress, facilitating communication, and navigating difficult medical decisions. For busy clinicians, palliative care teams can significantly improve patient care and save valuable time.
To assist in determining when a palliative care consultation would be beneficial, consider the following criteria. The presence of one or more of these indicators suggests a potential need for palliative care involvement.
General Palliative Care Referral Criteria: Presence of Serious Chronic Illness
- Decline in Activities of Daily Living: Noticeable worsening in a patient’s ability to perform everyday tasks such as bathing, dressing, or eating. This indicates a growing need for support and symptom management to maintain independence and comfort.
- Unexplained Weight Loss: Significant unintentional weight loss can be a sign of underlying disease progression and increased metabolic demands, often accompanied by symptoms that palliative care can address.
- Frequent Hospitalizations: Recurrent hospital admissions suggest difficulties in managing the patient’s condition in the outpatient setting and may signal a need for more comprehensive support to prevent future crises and improve stability at home.
- Difficult Symptom Management: Challenges in controlling physical or emotional symptoms like pain, nausea, anxiety, or depression related to a serious illness highlight the need for specialized palliative care expertise in symptom relief.
- Prognostic Uncertainty or Conflicting Goals: When there is uncertainty among the patient, family, or physician regarding the patient’s prognosis or the most appropriate goals of care, palliative care can facilitate crucial conversations and help clarify values and preferences.
- Requests for Futile Care: Expressions of wanting medical interventions that are unlikely to provide benefit or align with realistic outcomes signal a need for palliative care to explore goals of care and manage expectations.
- DNR Order Conflicts: Disagreements or difficulties surrounding Do Not Resuscitate (DNR) orders indicate a need for facilitated communication and ethical guidance that palliative care can provide.
- Artificial Nutrition in Advanced Illness: Considering tube feeding or Total Parenteral Nutrition (TPN) for patients with cognitive impairment or advanced serious illness requires careful consideration of burdens and benefits, which palliative care teams can help assess.
- Limited Social Support: Patients with serious illness who lack adequate social support systems, such as those experiencing homelessness or chronic mental illness, are particularly vulnerable and can benefit from the holistic support offered by palliative care.
- Hospice Information Requests: Inquiries about hospice care from patients, families, or physicians suggest a need for education and exploration of end-of-life care options, which palliative care can facilitate as a bridge to hospice or as concurrent care.
- Psychological or Spiritual Distress: Significant emotional or spiritual suffering experienced by the patient or family in the context of serious illness warrants palliative care’s interdisciplinary approach to address these non-physical dimensions of care.
Intensive Care Unit (ICU) Palliative Care Criteria
- Nursing Home Admission Prior to ICU: Admission to the ICU from a nursing home, especially with pre-existing chronic conditions like dementia, often indicates a complex clinical picture where palliative care can optimize comfort and care planning.
- Multiple ICU Admissions: Two or more ICU admissions within the same hospital stay signal a pattern of instability and high care needs that may be better addressed with a palliative approach focused on quality of life and goal-concordant care.
- Prolonged Ventilator Weaning: Difficult or extended ventilator withdrawal processes can be emotionally and physically challenging, and palliative care can provide support for the patient, family, and medical team.
- Multi-Organ Failure: The presence of failure in multiple organ systems signifies a critical illness with high mortality risk, where palliative care can focus on symptom management, comfort, and end-of-life planning if appropriate.
- Ventilator Withdrawal Consideration: When ventilator withdrawal is being considered with an anticipated poor prognosis, palliative care is essential to ensure a compassionate and comfortable process, aligning with patient and family wishes.
- Metastatic Cancer in the ICU: Patients with metastatic cancer requiring ICU admission often have complex symptom management and end-of-life care needs that palliative care is uniquely equipped to address.
- Anoxic Encephalopathy: Severe brain injury due to lack of oxygen carries a high risk of disability and mortality, often necessitating palliative care involvement to guide goals of care and manage neurological symptoms.
- Long-Term Ventilation Facility Consideration: Contemplating transfer to a long-term ventilator facility raises questions about long-term quality of life and goals of care, which palliative care can help clarify and align with patient values.
- Family Distress Impairing Decision Making: Significant family distress that hinders surrogate decision-making in the ICU setting requires palliative care’s expertise in communication, emotional support, and conflict resolution.
Oncology Palliative Care Criteria
- Advanced Cancer Progression: Metastatic or locally advanced cancer progressing despite systemic treatments, particularly when accompanied by weight loss and functional decline (Karnofsky Performance Status ≤ 3), strongly indicates the need for palliative care to manage symptoms and improve quality of life.
- Progressive Brain Metastases: Cancer spread to the brain that continues to progress after radiation therapy presents complex neurological symptoms and functional impairments that palliative care can help manage.
- Spinal Cord Compression or Neoplastic Meningitis: New spinal cord compression or neoplastic meningitis are oncologic emergencies causing pain and neurological deficits, where palliative care can be crucial for symptom control and supportive care.
- Malignant Hypercalcemia: Elevated calcium levels due to malignancy can cause significant symptoms and complications, requiring palliative care involvement for symptom management and supportive strategies.
- Progressive Effusions: Recurring pleural, peritoneal, or pericardial effusions related to cancer can cause discomfort and breathing difficulties, benefiting from palliative interventions to alleviate symptoms.
- Chemotherapy Failure: Failure of first or second-line chemotherapy regimens suggests advanced disease and a shift in focus towards symptom management and supportive care, making palliative care highly relevant.
- Painful Bone Metastases: Multiple painful bone metastases are a common source of significant pain and functional limitation in cancer patients, where palliative care can offer comprehensive pain management strategies.
- Interventional Pain Management Consideration: When considering interventional pain management procedures for cancer pain, palliative care can provide a holistic assessment and ensure these interventions are aligned with overall goals of care.
- Severe Pancytopenia in Hematologic Malignancy: Severe and prolonged pancytopenia in the context of untreatable hematological malignancies, like relapsed leukemia, indicates advanced disease where palliative care focuses on comfort and supportive care.
Emergency Department (ED) Palliative Care Criteria
- Frequent ED Visits: Multiple recent ED visits for the same symptoms or problems suggest ineffective outpatient management and a potential need for palliative care to improve symptom control and care coordination.
- Long-Term Care DNR/Comfort Care Orders: ED patients from long-term care facilities with Do Not Resuscitate (DNR) and/or Comfort Care (CC) orders require careful attention to their documented wishes and symptom management, which palliative care can facilitate.
- Prior Hospice Enrollment: Patients previously enrolled in hospice, whether at home or in a residential setting, who present to the ED may have complex end-of-life care needs or symptom exacerbations that palliative care can address in collaboration with hospice if still appropriate.
- Hospice Desire but No Referral: When a patient, caregiver, or physician expresses a desire for hospice care but a referral has not yet been made, the ED can be an opportunity to initiate a palliative care consultation to facilitate this process.
- ICU/Ventilation Consideration in High-Risk Patients: Considering ICU admission or mechanical ventilation in ED patients with metastatic cancer and functional decline, moderate to severe dementia, or multiple chronic diseases with poor baseline functional status, requires careful goals of care discussion and may be better served by a palliative approach focusing on comfort and quality of life rather than aggressive interventions.
These criteria are designed to guide clinicians in identifying patients who could benefit from palliative care. Early referral can significantly improve patient and family experiences, optimize symptom management, and align care with patient values and goals.
