Synopsis
Identify people who would benefit from palliative care on the basis of unmet need and deteriorating health, respond to urgent reversible problems, and coordinate proportionate generalist or specialist support without waiting for a precise prognosis.
- Palliative care is active care directed at quality of life, symptom relief, communication and support; it can begin while disease-directed treatment continues.
- Need, not diagnosis or estimated survival, is the first-line trigger. Advanced heart, lung, neurological, renal and liver disease can create needs comparable with metastatic cancer.
- Look for general deterioration, disease-specific progression, escalating service use, persistent symptoms, weight or function loss, treatment intolerance and caregiver strain.
- A negative answer to the surprise question can prompt review, but it is neither a diagnostic test nor a requirement for referral.
- First-line assessment is a direct holistic conversation covering physical symptoms, understanding, priorities, mood, relationships, practical concerns, spirituality and carer needs.
- There is no single gold-standard biomarker. The clinical benchmark is repeated multidisciplinary assessment linked to action, shared records and review after change.
- Generalist palliative care belongs to every clinician; specialist referral adds value for refractory symptoms, complex decisions, severe psychosocial distress or difficult coordination.
- Recognition must not become therapeutic pessimism: investigate and treat reversible illness when the likely benefit matches the person's goals.
- Record uncertainty honestly, identify who coordinates care and offer advance-care discussion without making planning forms a condition of receiving support.
Key red flags
New limb weakness, sensory change or sphincter dysfunction in cancer may indicate metastatic spinal cord compression and needs urgent pathway activation.
Major bleeding, stridor, status epilepticus, severe hypercalcaemia or uncontrolled breathlessness requires immediate clinical treatment alongside palliative support.
Fluctuating attention or altered arousal suggests delirium; search for pain, infection, medicines, hypoxia, urinary retention, faecal loading and biochemical causes.
Repeated crisis attendance, rapidly falling performance or inability to take essential medicines signals an unstable plan even when no single symptom seems dramatic.
A distressed or exhausted caregiver, unsafe home environment or safeguarding concern can make the present care arrangement clinically unsafe.
Statements about wanting to die require compassionate exploration of symptoms, depression, coercion, immediate suicide risk and decision-making capacity rather than dismissal as expected sadness.
Exhaustion, poor health, competing responsibilities, anticipatory grief or inability to provide overnight care can threaten both patient safety and caregiver wellbeing.
Investigation priorities
Elicit physical, psychological, social, information, practical, cultural, spiritual and caregiver concerns in the patient's preferred order.
Management branches
Progression, functional decline, repeated crisis or a clinician, patient or carer concern suggests unmet palliative need.
- Ask permission for a holistic conversation, establish immediate priorities and assess symptoms, function, understanding, supports and caregiver capacity.
- Treat urgent reversible problems and start core generalist measures while deciding whether complexity or instability requires specialist palliative input.
- Document goals, responsible professionals, out-of-hours contacts, review timing and what change should prompt an earlier reassessment.