Would You Refer This Patient With Cancer to a Palliative Care Specialist?

Abstract

TO THE EDITOR: I thank Reynolds and colleagues (1) for their thorough discussion on palliative care guidelines. I would like to offer several comments as part of the ongoing dialogue in this field. Their discussion of when to engage specialist-level palliative care services in relation to triggers or adverse events is helpful. However, as palliative care moves upstream (and specifically into primary care), I believe that this approach will only touch the surface and be applicable solely in emergency or episode-based situations. A more relevant population health management approachone potentially closely tied to evidence-based primary care and value-based paymentwould be based on case complexity. For example, patients with a risk stratification score of 5 or 6 on the American Academy of Family Physicians risk assessment tool; a refractory physical, psychosocial, or spiritual symptom burden; or multiple serious comorbidities would be eligible for palliative care. The Table in Reynold and colleagues article lists several applicable assessment tools. I recommend adding the Integrated Palliative Care Outcome Scale, because it secures real-time input from patients on their symptoms and is easily used to determine the outcome of treatment. The Centers for Medicare & Medicaid Services has researched this United Kingdombased tool, which is now in use internationally, and has approved it for use in Delivery System Reform Incentive Payment programs. The scope of palliative care models seems to exclude palliative home carethat is, care provided in the patient s home on an ongoing basis as his or her disease progresses as opposed to care provided in clinic settings. Programs that provide this care can be freestanding or part of certified home health agencies or public health departments. They have been shown to enable patients with advanced illness to substantially reduce hospitalization episodes and experience shorter lengths of stay when hospitalizations do occur. Better still, they give primary and specialist care providers comprehensive palliative care supports for homebound patients and stressed caregivers. These supports are more than one-off consultations and are patient residencebased.