To our knowledge, this is the first study in which the quality of referrals used for palliative care admissions in Poland is described. The majority of registered patients had advanced cancer, and were referred late during progressing phase of the disease, however, usually neither performance status nor prognosis were reported. This phenomenon was more evident, particularly, in the case of home care referrals, thus, as a consequence, these patients could have been more often negatively triaged and finally disqualified. The national reimbursement system, limited mainly to cancer patients, has been the main cause of referrals inequity for years. In 2021 only 26.7% of deaths were caused by neoplasms[13], however, prevalence of these patients within palliative care services in recent years fluctuates around 90%[14]. Despite the evidence of increasing access for people with non-malignant illnesses worldwide, the same inequity is visible from the beginning of the modern hospice movement in other countries[15]. This finding cannot be explained solely by the differences in needs between these two groups, as in the systematic review, it has been proved that there are commonalities in the prevalence of problems across cancer and non-cancer patients[16].
In spite of the fact that actual palliative care definitions are also concentrated on the earlier phases of the disease, in reality, patients continue to fear palliative care referral and associate it with cessation of active treatment and imminent death[17]. Many oncologists and haematologists, partially due to diminished trust in the competency of palliative care providers, presuppose referrals with therapeutic alliance and loss of hope and, in consequence, prefer to gatekeep this process, which appears to them as a daunting, time-consuming task[18],[19]. As a result, a substantial number of persons, despite evidence of a high level of unmet needs, the majority of patients are referred at the near the end of life phase[20]. What is more, delayed referrals depend not only on late initiation of serious illness conversation or prognostication made by physicians, but also may be the result of patients’ or family caregivers’ wrong perspectives of palliative care[21]. This care could incorrectly be associated as an inferior form of treatment or even approaching death, and such referral can be emotionally devastating. Finally, lack of experience of palliative care providers among patients with non-malignant diseases pose complex problems, and the insufficiency of these centres due to excessive burden of cancer patient admissions could be another reason for late referrals[22].
In more than half of the cases in our study, the only indication for specialist PC was the presence of illness contained within the strict catalogue of the national reimbursement system, which encompasses the majority of all cancers. Apart from formal or legal provisions, these findings can be supported by the observation that referrals are influenced by complex appraisal of the situation, which goes beyond the patients’ pure prognosis or needs[23]. This assessment takes other factors into account: e.g. the needs of the referring physician, one’s emotional capacity, expertise, available time, interpretation of patients preferences or fears, and also assumptions about professional quality of palliative services in light of the patients’ previous input. Although it is hard to objectively detail what makes PC needs “complex” for referral to a specialist care, the percentage of reported needs on referrals in other surveys was much higher than in our study: physical needs were recorded for 76 to 91%, psychological issues for 59%, and spiritual concerns for 55% of cases[11],[24].
Instead of reporting patients’ needs, nearly one-third of RFs in our survey were labelled as “urgent”, with near half of them lacking any notice of unresolved problems. This label was quite irrelevant in half of the situations, as the additional documentation or telephone interviews did not reveal any urgent reasons for the admission, and one of eight persons could have been cared for by a GP. This turns out to be similar as in the literature, in which it was found that health care providers lack knowledge and clarity regarding referrals, thus, additional education is required[25],[26].
The main suspected reason for this discrepancy between referring a physician’s convictions regarding PC necessity and a patient’s actual needs in our study may depend on the lack of a dedicated tool available in majority of cases for general physicians doctors, helping them in the routine screening of their patients’ needs. A number of validated screening tools are available free-of-charge, e.g. in Australia, the RUN-PC triage tool[27] with a dedicated web calculator[28] or in Germany, the Hospice and Palliative Care Evaluation Symptoms and Problems Checklist[29]. However, the ability of them to triage cases that are likely to have palliative needs in primary care is still limited and further research is warranted[4].
Revealing the essential information for preliminary qualification for palliative care may also facilitate the accurate assessment of urgent indications for admission. It may simplify and accelerate the process, in consequence, lowering costs[30]. However, the integrative models assume a substantial role of standard care interventions, including symptom assessment, concerns regarding decision-making and advance care planning, supplemented by specialist care, when general care has failed to achieve desirable effects[31]. Routine usage of referral templates could improve the “quality” of referrals but in reality, despite their accessibility, their feasibility in routine clinical practice could be challenging[32].
However, we noted that only in half of the cases was undisturbed triage possible solely based on RF, therefore, in every-second patient, this qualification process had to be unnecessarily extended. This phenomenon was particularly visible when the patient was discharged from hospital. Whereas the evaluation of palliative needs is feasible from admission to hospital, also within the intensive care unit, the selection of potential candidates is done in advance. This allows changing care priorities, while facilitating timely referrals[33]. Building a collaborative team within the hospital ward and wisely choosing the available hospital supportive teams is crucial, particularly, in non-cancer patients[34],[35]. An approach that allows these teams to assess treatment objectives engages the treating physician and improves the use of services[36]. Unfortunately, the actual national reimbursement system in Poland does not provide financial backing for such hospital supportive care teams, thus, in the majority of cases, leaving physicians to rely solely on their skills and knowledge.
We found that in nearly one-fifth of referrals continuous palliative care was not necessary, as the outpatient supportive consultations seemed to be sufficient. General physicians should have basic knowledge of symptomatic management, communication skills to face and share “bad news” and discuss advanced care plans in a reaction of palliative staff deficiency[31]. They should be sufficiently equipped with both prognostic and screening tools used in routine practice. Despite the fact that primary care physicians, in most situations, should be the crucial providers of PC in communities, local partnerships with PC centers are strongly recommended[12]. Generalists should cooperate with the specialist outpatient PC at least within a consultation model, when consultants do not need to take over all aspects of care[37]. What is more, the whole health care system should also facilitate primary care development, with adequate resources and financial incentives to support education as well as collaboration within the interdisciplinary teams[38].
In our study, more than a quarter of inpatient referrals had unresolved social problems, which could be challenging in implementing hospice home care. However, admissions of patients with predominantly social needs to specialised PC wards can be considered as an improper use of these resources. The development of general home care social support and long-term care facilities deserved more attention in these cases. Such types of care should be supported by palliative consultations based on the existence of patients’ complex needs[39]. Moreover, amongst vulnerable individuals, e.g. experiencing homelessness, an additional professional health nurse navigator or case manager should coordinate healthcare transitions, facilitating timely referral[40],[41],[42]. Effective family caregiver support programmes could also improve this integration[43]. Strengthening people’s social network via the concept of compassionate communities is urgently needed as well[44].
The screening process in this study was limited to a single centre within the district town, and there were no prospective or retrospective follow-ups among the patients in terms of their problems and needs. Moreover, the role of the caregivers in the referral process was not evaluated. Further multicentre studies evaluating the screening tools with the adequate follow up are warranted.