Guidelines can help identify unmet palliative care needs

In past entries of this column, we have written a lot about what palliative care is, the skills that are required to deliver it and the specific symptom-management guidelines associated with it.

The Center to Advance Palliative Care — an organization that provides professional tools, training and technical assistance to start and sustain palliative care programs — recently convened a consensus panel to select criteria by which hospitalized patients at high risk for unmet palliative care needs can be identified.

The panel developed two screening checklists, one that can be used at the time of admission and another that can be used for daily patient rounds. The checklists were published as part of a special report in the Journal of Palliative Medicine.

The checklists — which can be applied to office practices, as well — are divided into primary and secondary criteria.

Biren Saraiya

The panel defined “primary palliative care” as the basic skills and competencies required of all physicians and health care professionals. It defined “secondary palliative care” as that which is provided by specialist clinicians who provide consultation and specialty care. These clinicians, such as cardiologists, pulmonologists and other subspecialists, provide support and assistance to primary care providers.

Assessment procedures

The panel outlined several components of the primary palliative care assessment.

They include evaluating patients’ pain and symptoms; their social and spiritual concerns; and their understanding of their illness, prognosis and treatment options. Ultimately, those components help establish what the panel defined as patient-centered goals of care, including ensuring treatment is matched to the patient’s goals and determining whether the patient has completed an advance care planning document.

The panel developed several criteria to help identify which patients with potentially life-threatening or life-limiting conditions may benefit most from a palliative care assessment.

The first is what the panel called the “surprise question,” meaning a physician would not be surprised if the patient died within 12 months.

Other primary criteria include frequent admissions for the same condition within several months (with an exception for admissions for chemotherapy); difficult-to-control physical or psychological symptoms that require admission; complex care requirements; a decline in function or failure to thrive; and no history of advance care planning.

Secondary criteria include metastatic or locally advanced incurable cancer; chronic home oxygen use; limited social support; and current or previous enrollment in a hospice program.

A positive finding on any of the above criteria likely will lead to a discussion about the goals of care and, based on performance status, a change in therapy.

The discussion must include assessing a patient’s understanding of the disease and treatment goals. The clinician must offer his or her impressions in a truthful manner.

Implementation

Each patient should be screened for these symptoms at every major junction in their disease trajectory, including at their first visit or diagnosis of terminal illness, as well as after every restaging and every time new therapies are discussed.

The occasions when nurses evaluate patients for toxicity also may serve as opportunities to ask the assessment questions.

Several questions already should be asked as part of the routine clinical evaluation at each physician and treatment visit.

They include:

• Do you have any pain? If yes, describe it or quantify it.
• Do you have other symptoms?
• How are you dealing with your illness? Inquire about emotional, spiritual and practical concerns patients may have.
• Have you completed an advance care plan?

Although not all questions are asked during each visit, a comprehensive approach will provide reassurance that each patient is evaluated.

Practitioners also should ask themselves whether they would be surprised if the patient died within a year. If so, it becomes the practitioner’s responsibility to ensure the patient has that knowledge.

Once a patient is screened, the next step would be to either prescribe treatments to address his or her needs or to consult with others who can help the patient. They may include those the consensus panel identified as secondary palliative care professionals, as well as social workers, chaplains or pain specialists.

Streamlining the inpatient and outpatient screening processes will allow for improved patient care and also increase the chances that all patients are screened appropriately.

Biren Saraiya, MD, is an assistant professor at the Cancer Institute of New Jersey at UMDNJ-Robert Wood Johnson Medical School. He also is a member of the HemOnc Today Editorial Board. Disclosure: Dr. Saraiya reports no relevant financial disclosures.

For more information:

• Center to Advance Palliative Care. www.capc.org.
• Weissman DE. J Palliat Med. 2011;14:17-23.