Yesterday I had the opportunity to participate in an excellent webcast sponsored by the Center to Advance Palliative Care (CAPC) and presented by Dr. David Weissman, professor emeritus from the Medical College of Wisconsin. Dr. Weissman discussed the potential to use consult triggers (i.e. objective patient- or disease-specific criteria) to help increase referrals for palliative care consults and increase the likelihood that they are made in a timely way.
Triggers may include disease variables such as a diagnosis of metastatic cancer or stage IV CHF, or patient variables such as two or more hospitalizations during a one month period or an ICU stay of longer than X days.
In the presentation, Dr. Weissman outlined five key steps for successful implementation:
- Define your goals. Hospitals may want to use consult triggers to increase referrals to palliative care, meet unmet patient needs or achieve specific institutional goals such as cost reduction. It's important to define these goals upfront and determine how the organization will measure progress against them.
- Evaluate staffing needs. In most cases, consult triggers will result in increased referrals to the pallaitive care team. Consequently hospitals must forecast this change and ensure that their palliative care team is staffed to manage the growth.
- Secure buy in from stakeholders. In order for consult triggers to be effective, referring clinicians must be on board. To gain their support, palliative care leaders should seek to understand clinicians' needs (e.g. difficulty discussing end-of-life care, fear that patients and families will think they are "giving up") and design palliative care services to support them.
- Select consult triggers. Currently there is no consensus as to the "best" consult triggers and little data is available on the relative effectivess of specific criteria. Consequently, each institution should select criteria that reflect their goals and refine them through a process of trial and error. It is imperative to involve referring clinicians in this process, as they are best postitioned to anticipate the potential obstacles to implementation and the impact on workflow.
- Determine the process for applying consult triggers. Generally speaking, there are two possible approaches. Consult triggers may lead to further triage, which may or may not result in the patient being scheduled for a palliative care consult. Or alternatively, triggers may lead directly to a consult. Once a process has been chosen, program leaders must also determine who will take responsibility for each step.
Dr. Weissman acknowledged that simply following the steps outlined above is insufficient to guarantee success; rather there are numerous potential pitfalls to be aware of. Some of the most common include:
- Lack of buy in from referring clinicians
- Inaccurate estimates of palliative care consult volumes following implementation of triggers
- Poorly calibrated triggers resulting in inappropriate referrals
- Triggers placing undue burden on referring clinicians
Given that there is a shortage of palliative care-trained specialists, program leaders must think carefully about which patients are in need of specialized palliative care. All clinicians should be able to diagnose and address basic palliative care needs. Palliative care specialists should only become involved in those cases where patients have specialized needs.
For more information, Dr. Weissman recently co-authored a paper with CAPC director Diane Meier on on consult triggers in the hospital setting (available here). In addition, CAPC provides samples of palliative care consult assessment tools on its website here.