This Advocacy Alert addresses case finding for patients with unmet palliative care needs in any health care setting. In order of frequency, the following methods are currently used:
Method 1. Physician referral based on an identified problem, most commonly helping patients determine the appropriate match of medical interventions to prognosis or difficult to control symptoms. In a few settings, nurses or patients can initiate a referral. This approach has the drawback of being clinician, not patient centered, introducing clinician biases into a) identifying the unmet need and b) determining the need and timing for specialist involvement.
Method 2. A screening tool (aka trigger system) is used to identify patients with unmet needs who are then referred to specialist palliative care services, either automatically or by asking the attending clinician for a referral. This approach is increasingly used in settings like the ED, ICU, oncology or heart failure clinic.
Method 3. A screening tool is used to identify patients with unmet needs. Once identified, a system is established whereby generalist clinicians (e.g. hospitalist, unit nurse) complete a set of tasks (e.g. encourage ACP documentation, conduct a goal of care discussion, complete a thorough symptom assessment). Referral to a palliative care specialist is reserved for patients whose needs cannot be met by the generalist team.
Choice of Screening Tool
Many different approaches to screening have been developed. The two most common include …
A single indicator, most often The Surprise Question: would you be surprised if this patient died within the next 12 months (or shorter depending on setting)
Combination of indicators taken from the published literature (1)
PCNOW strongly believes that a patient-centered approach to care, that minimizes care variation, includes a system to prospectively identify patients with unmet palliative care needs, irrespective of diagnosis, prognosis, or care setting. The following steps can be taken to develop the process in your setting.
Gather a small committee to explore case finding options.
Collect data that a problem exists.
If your setting already has a specialist palliative care program, a simple method is to count the number of referrals over a given period of time from different clinicians (e.g. all hospitalists) or different care units, searching for variation that would indicate unequal patient access to specialty palliative care services.
In the hospital setting you can get data on the ratio of specialist palliative care referrals to inpatient deaths, measured in different care units or across a cohort of clinicians; again, searching for unacceptable variation.
Make a decision about developing a system that will assess all patients, or just those in a certain care setting (e.g. oncology clinic).
Invite key stakeholders to participate in determining what screening tool(s) will be used to identify patients.
Discuss the role of generalist clinicians vs. palliative care specialists in managing the unmet needs.
Once you have identified a process for patient identification and management, test the process with a small cohort of patients, revise and retest.
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1. Weissman DE and Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: consensus recommendations. J Pall Med 2011;14:1-7.