Photo Credit: Jacob Wackerhausen

Researchers identified 17 major and 30 minor criteria to guide physicians in referring their patients with COPD to specialty palliative care.

Identifying appropriate patients with COPD for specialist outpatient palliative care can be challenging, highlighting a need for clearer criteria for palliative care referrals. Jennifer Philip and colleagues identified potential referral criteria in a Delphi study published in Thorax.

“Early palliative care offers important benefits for people with COPD and their families, but currently access to these services is variable, and usually late,” Phillip told Physician’s Weekly. “These criteria have been developed to act as a prompt for clinicians to consider palliative care referral. Using these criteria will reduce the variation in care currently observed.”

Surveying Experts

The Delphi study started with the creation of a steering committee of experts in respiratory medicine, palliative care, and primary care. Committee members were from Australia, Japan, Taiwan, the US, the UK, Sweden and Chile.

Eligible panelists received three surveys; each was open for 4 weeks, and surveys were spaced 4 weeks apart. In the first survey, experts ranked 81 criteria on a Likert scale from 1-5.

The steering committee grouped the criteria into eight categories:

• Hospital utilization
• Respiratory therapies
• Distressing symptoms
• Exacerbation
• Prognosis
• Functional impairment
• Comorbidities and complications
• Psychosocial factors

In the second survey, experts were asked to rank the criteria into three categories: major (triggering referral on its own), minor (leading to referral when seen in combination with at least one other minor criteria) and inappropriate (not triggering a referral).

For the third survey, experts confirmed any criteria that showed 70% or more consensus in survey two.

What Are the Major Criteria?

Seventeen major criteria emerged, which fell into three categories: health services, presence of symptoms or psychosocial needs, and withdrawal of life-prolonging interventions.

The seventeen major criteria were:

• Two or more hospitalizations in the past 3 months
• Two or more ICU episodes in the past 12 months
• Use of non-invasive ventilation
• Non-invasive ventilation (NIV) due to acute or acute-on-chronic respiratory failure (past 6 months)
• Need for home NIV
• Lung transplantation assessment
• Episode of extracorporeal membrane oxygenation use (past 12 months)
• Severe chronic breathlessness
• Severe physical symptoms
• Severe emotional symptoms
• Severe physical symptoms
• Severe existential dread
• Request for assisted suicide
• Patient or family request or distress
• Withdrawal or de-escalation of life-prolonging interventions
• Life expectancy of six months or less
• Patient walks less than 100 meters in 6 minute walk test
• Karnofsky performance status is 30 or less, but no risk of death is indicated

What Are the Minor Criteria?

The group reached consensus on 30 minor criteria. When two or more minor criteria are present, a physician should refer a patient with COPD to palliative care.

The 30 minor criteria were:

• One or more advanced chronic medical conditions other than COPD
• Chronic hypercapnia greater than 65 mm Hg
• Hypoxemia less than 55 mm Hg
• Cognitive impairment
• Two or more incidents of community-managed exacerbation of COPD during the past 3 months
• Continuous systemic corticosteroids required for 3 or more months in the past 12 months
• Unresponsive to usual treatment
• A BODE index greater than or equal to seven
• Life expectancy of 12 months or less
• Patient walks less than 200 meters in 6 minute walk test
• Karnofsky performance status 50
• Cannot complete three or more basic daily activities without assistance
• Consistent trajectory of decline
• Referral for hospice or a discussion about hospice
• Moderate chronic breathlessness
• Moderate physical symptoms
• Moderate emotional symptoms
• Moderate spiritual/existential distress
• Severe distress from a healthcare professional
• Poor social support
• Chronic opioid therapy
• Patient does not elect life-sustaining treatments
• Patient cannot make care decisions without assistance
• Two or more ER visits within the past six months related to COPD or complications
• Two or more hospitalizations related to COPD or complications in the past year
• One or more ICU admissions for COPD or complications in the past year
• One or more admissions to a high dependency unit due to COPD or complications within the last 6 months
• Acute hospital stay of 14 days or more due to COPD or related complications
• NIV use for acute or acute chronic respiratory failure in the past year
• Home oxygen required

Limitations and Applications

Philip and the team noted only a small number of panelists were from South America and Asia, and none were from the Middle East or Africa. Still, the criteria were developed with diverse palliative care settings in mind.

“There are substantial differences in the systems and resources for care of people with COPD across the world. In developing these criteria, the international panel noted the importance of establishing consensus on best practice, which may then serve as a valuable focus for advocacy,” Philip says.