For Clinicians

Is your patient appropriate for a palliative care referral? Palliative care is based strictly on need, not prognosis. A palliative care consultation will assist you in managing complex pain, symptoms, comorbidities, patient/family communication and other issues. Palliative care teams will also save you time.

The following general referral criteria have been developed to help you assess whether a palliative care consultation would be beneficial to you and your patient. One or more of the following criteria may indicate the need for referral to the palliative care team:

Overall: Presence of a Serious, Chronic Illness

• Declining ability to complete activities of daily living
• Weight loss
• Multiple hospitalizations
• Difficult to control physical or emotional symptoms related to serious medical illness
• Patient, family or physician uncertainty regarding prognosis or goals of care
• Requests for futile care
• DNR order conflicts
• Use of tube feeding or TPN in cognitively impaired or seriously ill patients
• Limited social support and a serious illness (e.g., homeless, chronic mental illness)
• Patient, family or physician request for information regarding hospice appropriateness
• Patient or family psychological or spiritual distress

Intensive Care Unit Criteria

• Admission from a nursing home in the setting of one or more chronic conditions (e.g., dementia)
• Two or more ICU admissions within the same hospitalization
• Prolonged or difficult ventilator withdrawal
• Multi-organ failure
• Consideration of ventilator withdrawal with expected death
• Metastatic cancer
• Anoxic encephalopathy
• Consideration of patient transfer to a long-term ventilator facility
• Family distress impairing surrogate decision making

Oncology Criteria

Metastatic or locally advanced cancer progressing despite systemic treatments with or without weight loss and functional decline;

• Karnofsky < 50 or ECOG > 3
• Progressive brain metastases following radiation
• New spinal cord compression or neoplastic meningitis
• Malignant hypercalcemia
• Progressive pleural/peritoneal or pericardial effusions
• Failure of first – or second-line chemotherapy
• Multiple painful bone metastases
• Consideration of interventional pain management procedures
• Severe prolonged pancytopenia in the context of an untreatable hematological problem (e.g., relapsed leukemia)

Emergency Department Criteria

• Multiple recent prior hospitalizations with same symptoms/problems
• Long-term-care patient with Do Not Resuscitate (DNR) and/or Comfort Care (CC) orders
• Patient previously enrolled in a home or residential hospice program
• Patient/caregiver/physician desires hospice but has not been referred
• Consideration of ICU admission and or mechanical ventilation in a patient with:
  • metastatic cancer and declining function
  • moderate to severe dementia
  • one or more chronic diseases and poor functional status at baseline

Ten Steps for What to Say and Do

Additional resources on palliative care:

For more information on palliative care, and for courses for the non-palliative care specialist, visit the Center to Advance Palliative Care at www.capc.org.

For the National Consensus Project (NCP) Guidelines, go to www.nationalconsensusproject.org.

For the National Quality Forum (NQF), National Framework and Preferred Practices for Palliative and Hospice Care Quality, go to www.qualityforum.org.