Admission Criteria

Executive Summary

This document highlights the importance of distinguishing between a general palliative care approach and palliative care services with limited resources. A general palliative care approach aims to ensure comfort and improve the quality of life for individuals with life-threatening illnesses, even when there is a possibility of a cure. Palliative care programs, however, must allocate their limited resources and focus on those in greatest need.

Common eligibility criteria for palliative care programs include a specific prognosis of six months or less, a decision to prioritize comfort over cure, and an acceptance that resuscitation will not be used for a natural death. Ideally, palliative care should be integrated from the time of diagnosis to address pain, symptoms, and complex decision-making. Early consultation with a palliative care approach can be beneficial, particularly in aggressive illnesses with limited treatment options.

Home based palliative care is typically offered to individuals expected to die within a specific timeframe, often within six months, with a shift in care goals towards comfort. The availability of highly technical tests and treatments may vary among programs, with some requiring patients and families to understand that these options may not be available. Resuscitation, such as cardiopulmonary resuscitation (CPR), is generally not offered by palliative care programs, as it is not effective in cases where the underlying illness has overwhelmed the body.

The referral process for palliative care varies, often involving a referral form completed by the patient's physician or healthcare team. Communication and readiness cues from both the healthcare team and the patient and family play a role in initiating palliative care, and delays in discussing care preferences may hinder timely access to palliative services.

It is important to consider these criteria and processes within the context of available resources and program philosophies when making decisions about palliative care. By understanding these distinctions, healthcare providers can ensure appropriate and timely access to palliative care for individuals with life-threatening illnesses.

Identifying Patients Candidates for Home Based Care

"Would you be surprised if this patient died in 1 year?"

YES : Does Not Require Palliative Care

NO : + 1 of the Following

Parameters

Palliative Care Need	The person, health care professionals and/or family consider that the patient actually requires palliative care.
Functional Decline	There is a clinical impression of sustained functional decline, severe, progressive and irreversible and/or loss of 30% in Barthels index in 6 months.
Nutritional Loss	Clinical Impression of sustained nutritional decline, severe, progressive and irreversible and/or loss of 10% of weight loss in 6 months.
Multimorbidity	2 or more chronic concomitant to the principal diagnosis.
Resource Use	2 or more admission to a health facility during the past year and/or need for complex/intense management.
Advanced Disease	Severity Criteria and/or progression of chronic condition (example Cancer, lung, renal, cardiac).

Requires Palliative Care

1-2 Parameter	3-4 Parameter	4-6 Parameter
38 Months	18 Months	4 Months
	Consider Admission	Admission

Severity Criteria, Progression of Chronic Illness

Oncologic Disease	Advanced metastatic or locoregional cancer Progressive Disease (in solid tumors) Persistent symptoms that are poorly controlled or refractory despite optimizing the specific treatment
Chronic Pulmonary Disease	Dyspnea at rest or on minimal exertion between exacerbations Confined to home with limited movement Spirometric criteria for severe obstruction (VEMS <30%) or criteria severe restrictive deficit (forced CV <40% / DLCO <40%) Baseline blood gas criteria for chronic home oxygen therapy. Need for continued corticosteroid therapy Associated symptomatic heart failure
Chronic Cardiac Disease	Dyspnea at rest or with minimal effort between exacerbations NYHA stage III or IV heart failure, valvular disease severe non-surgical or non-revascularizable coronary artery disease Baseline echocardiography: EF <30% or severe HTAP (PAPs> 60) Associated renal failure (GFR <30 l/min) Association with renal failure and persistent hyponatremia
Dementia	Cognitive, functional, and/or nutritional decline progression Global Deterioration Scale (GDS) ≥ 6c
Fragility	Fragility Index ≥ 0.5 (Rockwood K et al, 2005) Comprehensive geriatric evaluation suggestive of advanced frailty (Stuck A et al, 2011)
Vascular Neurological Disease (stroke)	During the acute and subacute phase (<3 months post-stroke): state persistent vegetative or minimal consciousness> 3 days During the chronic phase (> 3 months post-stroke): medical complications repeated (or dementia with post-stroke severity criteria)
Degenerative Neurological Disease (Parkinsons, ALS)	Progressive deterioration of physical and/or cognitive function Complex and difficult to control symptoms Persistent dysphagia/speech disorder Increasing communication difficulties Recurrent aspiration pneumonia, dyspnea or respiratory failure
Chronic Liver Disease	Advanced cirrhosis Child C stage (determined outside of complications or having treated them and optimized the treatment), MELD-Na> 30 or refractory ascites, hepato-renal syndrome or upper gastrointestinal bleeding due to Persistent portal hypertension despite optimizing treatment. Hepatocellular carcinoma in stage C or D
Chronic Kidney Disease	In severe renal failure (GFR <15) in patients who are not candidates or with rejection of replacement treatment and/or transplant Dialysis completion or transplant failure

Patients in Need of Home-Based Palliative Care

Domains	Instruments
Symptom Assessment	ESAS
Physical Assessment	Physical examination
Functional Assessment	ECOG (oncologic) BARTHEL (non oncologic)
Cognitive Assessment	Mini-Mental
Spiritual Assessment	Chaplain Assessment Explicit Spiritual Concerns of Patients in Palliative Care.
Caregiver Assessment	DME Scale
Social Assessment	Gijon Scale