Supportive Care in Cancer

, Volume 26, Issue 1, pp 175–180 | Cite as

Automatic referral to standardize palliative care access: an international Delphi survey

  • David HuiEmail author
  • Masanori Mori
  • Yee-Choon Meng
  • Sharon M. Watanabe
  • Augusto Caraceni
  • Florian Strasser
  • Tiina Saarto
  • Nathan Cherny
  • Paul Glare
  • Stein Kaasa
  • Eduardo Bruera
Original Article



Palliative care referral is primarily based on clinician judgment, contributing to highly variable access. Standardized criteria to trigger automatic referral have been proposed, but it remains unclear how best to apply them in practice. We conducted a Delphi study of international experts to identify a consensus for the use of standardized criteria to trigger automatic referral.


Sixty international experts stated their level of agreement for 14 statements regarding the use of clinician-based referral and automatic referral over two Delphi rounds. A consensus was defined as an agreement of ≥70% a priori.


The response rate was 59/60 (98%) for the first round and 56/60 (93%) for the second round. Twenty-six (43%), 19 (32%), and 11 (18%) respondents were from North America, Asia/Australia, and Europe, respectively. The panel reached consensus that outpatient palliative care referral should be based on both automatic referral and clinician-based referral (agreement = 86%). Only 18% felt that referral should be clinician-based alone, and only 7% agreed that referral should be based on automatic referral only. There was consensus that automatic referral criteria may increase the number of referrals (agreement = 98%), facilitate earlier palliative care access, and help administrators to set benchmarks for quality improvement (agreement = 86%).


Our panelists favored the combination of automatic referral to augment clinician-based referral. This integrated referral framework may inform policy and program development.


Critical pathways Delphi technique Neoplasms Outpatients Palliative care Referral and consultation Standards 


Compliance with ethical standards


This study is partly supported by a grant from the Multinational Association of Supportive Care in Cancer. D.H. is supported in part by a National Institutes of Health grant (R21CA186000-01A1), an American Cancer Society Mentored Research Scholar Grant in Applied and Clinical Research (MRSG-14-1418-01-CCE), and an Andrew Sabin Family Foundation Fellowship. We would like to thank all the Delphi panel participants for their expert input.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Adelson K, Paris J, Smith CB, Horton J, Morrison SR (2013) Standardized criteria for required palliative care consultation on the solid tumor oncology service. In: Editor (ed)^(eds) Book standardized criteria for required palliative care consultation on the solid tumor oncology service. J Clin Oncol, City, pp. Abstact 37CrossRefGoogle Scholar
  2. 2.
    Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, Hull JG, Li Z, Tosteson TD, Byock IR, Ahles TA (2009) Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 302(7):741–749CrossRefGoogle Scholar
  3. 3.
    Board IOMNCP (2001) Improving palliative care for cancer. Institute of Medicine, Washington, DCGoogle Scholar
  4. 4.
    Calton BA, Alvarez-Perez A, Portman DG, Ramchandran KJ, Sugalski J, Rabow MW (2016) The current state of palliative care for patients cared for at leading US cancer centers: the 2015 NCCN Palliative Care Survey J Natl Compr Cancer Netw 14(7): 859–866CrossRefGoogle Scholar
  5. 5.
    Doorenbos AZ, Starks H, Bourget E, McMullan DM, Lewis-Newby M, Rue TC, Lindhorst T, Aisenberg E, Oman N, Curtis JR, Hays R, Clark JD, Baden HP, Brogan TV, Di Gennaro JL, Mazor R, Roberts JS, Turnbull J, Wilfond BS (2013) Examining palliative care team involvement in automatic consultations for children on extracorporeal life support in the pediatric intensive care unit. J Palliat Med 16(5):492–495CrossRefGoogle Scholar
  6. 6.
    Hui D, Bansal S, Strasser F, Morita T, Caraceni A, Davis M, Cherny N, Kaasa S, Currow D, Abernethy A, Nekolaichuk C, Bruera E (2015) Indicators of integration of oncology and palliative care programs: an international consensus. Ann Oncol 26(9):1953–1959CrossRefGoogle Scholar
  7. 7.
    Hui D, Bruera E (2016) Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol 13(3):159–171CrossRefGoogle Scholar
  8. 8.
    Hui D, Bruera E (2017) The Edmonton symptom assessment system 25 years later: past, present and future developments. J Pain Symptom Manag 53:630–643CrossRefGoogle Scholar
  9. 9.
    Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E (2014) Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer 120(11):1743–1749CrossRefGoogle Scholar
  10. 10.
    Hui D, Masanori M, Watanabe S, Caraceni A, Strasser F, Saarto T, Cherny N, Glare P, Kaasa S, Bruera E (2016) Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol 17(12):e552–e559CrossRefGoogle Scholar
  11. 11.
    Hui D, Park M, Liu D, Reddy A, Dalal S, Bruera E (2015) Attitudes and beliefs toward supportive and palliative care referral among hematologic and solid tumor oncology specialists. Oncologist 20(11):1326–1332CrossRefGoogle Scholar
  12. 12.
    Hui D, Titus A, Curtis T, Ho-Nguyen VT, Frederickson D, Wray C, Granville T, Bruera E, McKee DK, Rieber A (2017) Implementation of the Edmonton symptom assessment system for symptom distress screening at a community cancer center: a pilot program. Oncologist. doi: 10.1634/theoncologist.2016-0500 CrossRefGoogle Scholar
  13. 13.
    Levy MH, Smith T, Alvarez-Perez A, Back A, Baker JN, Beck A, Block S, Dalal S, Dans M, Fitch TR, Kapo J, Kutner J, Kvale E, Misra S, Mitchell W, Portman DG, Sauer TM, Spiegel D, Suzumilowicz E, Taylor RM, Temel J, Tickoo R, Urba SG, Weinstein SM, Zachariah F (2016) NCCN clinical practice guidelines in oncology. Palliative care. In: Editor (ed)^(eds) Book NCCN Clinical Practice Guidelines in Oncology. Palliative Care. National Comprehensive Cancer Network, CityGoogle Scholar
  14. 14.
    Rocque GB, Campbell TC, Johnson SK, King J, Zander MR, Quale RM, Eickhoff JC, Cleary JF (2015) A quantitative study of triggered palliative care consultation for hospitalized patients with advanced cancer. J Pain Symptom Manag 50(4):462–469CrossRefGoogle Scholar
  15. 15.
    Schenker Y, Crowley-Matoka M, Dohan D, Rabow MW, Smith CB, White DB, Chu E, Tiver GA, Einhorn S, Arnold RM (2013) Oncologist factors that influence referrals to subspecialty palliative care clinics. J Oncol Pract / Am Soc Clin Oncol 10(2):e37–e44CrossRefGoogle Scholar
  16. 16.
    Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, Ferrell BR, Loscalzo M, Meier DE, Paice JA, Peppercorn JM, Somerfield M, Stovall E, Von Roenn JH (2012) American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol 30(8):880–887CrossRefGoogle Scholar
  17. 17.
    Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363(8):733–742CrossRefGoogle Scholar
  18. 18.
    Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, Moore M, Rydall A, Rodin G, Tannock I, Donner A, Lo C (2014) Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 383(9930):1721–1730CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • David Hui
    • 1
    Email author
  • Masanori Mori
    • 2
  • Yee-Choon Meng
    • 1
    • 3
  • Sharon M. Watanabe
    • 4
  • Augusto Caraceni
    • 5
  • Florian Strasser
    • 6
  • Tiina Saarto
    • 7
  • Nathan Cherny
    • 8
  • Paul Glare
    • 9
  • Stein Kaasa
    • 10
    • 11
  • Eduardo Bruera
    • 1
  1. 1.Department of Palliative Care, Rehabilitation and Integrative Medicine, Unit 1414The University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Palliative Care TeamSeirei Mikatahara General HospitalShizuokaJapan
  3. 3.Department of Palliative CareTan Tock Seng HospitalSingaporeSingapore
  4. 4.Division of Palliative Care Medicine, Department of OncologyUniversity of AlbertaEdmontonCanada
  5. 5.Palliative Care, Pain Therapy and RehabilitationFondazione IRCCS Istituto Nazionale dei Tumori di MilanoMilanItaly
  6. 6.Oncological Palliative Medicine, Hematology-OncologyCantonal HospitalSt. GallenSwitzerland
  7. 7.Department of Palliative CareUniversity of Helsinki and Cancer Center, Helsinki University HospitalHelsinkiFinland
  8. 8.Cancer Pain and Palliative Medicine Service, Department of Medical OncologyShaare Zedek Medical CenterJerusalemIsrael
  9. 9.Pain and Palliative Care Service, Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkUSA
  10. 10.European Palliative Care Research Centre, Department of Cancer Research and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
  11. 11.Department of OncologyOslo University Hospital and University of OsloOsloNorway

Personalised recommendations