RPD200 - Acute Events Drive Late Palliative Care Referrals: Diagnosis-Specific Timing Patterns in Older Adults

Key Message : In 3,349 older adult decedents, over half of palliative care referrals occurred within 30 days of death. Cerebrovascular disease strongly predicts late referrals while dementia predicts earlier consultation. Healthcare systems should implement dual referral pathways: rapid-response protocols for acute crises and proactive monitoring for predictable chronic decline.

Abstract:

Background: While early palliative care (PC) improves outcomes [1, 2], real-world referral timing often appears reactive and crisis-driven rather than proactive [3, 4].

Objectives: To identify diagnosis-specific patterns in PC referral timing, with focus on distinguishing acute event triggers from chronic condition trajectories.

Methods: Retrospective cohort study of 3,349 older adult decedents (age ≥65) who received PC at a large academic medical center (2010-2023). Primary outcome was late PC referral (≤30 days before death). We used multivariable logistic regression to identify independent predictors of late referral, adjusting for demographics and individual chronic conditions. Multimorbidity burden was quantified as the total count of 10 common chronic conditions (hypertension, hyperlipidemia, diabetes, COPD, dementia, cancer, coronary heart disease, cerebrovascular disease, arthritis, congestive heart failure) identified via ICD codes.

Results: The cohort had a mean age at death of 75.1±6.0 years, was 54.5% male and 94.5% White, with a mean of 4.5±2.1 chronic conditions. PC was initiated profoundly late, with a median of just 25 days before death (IQR 8-96) and a majority of patients (54.4%) receiving a late referral. Cerebrovascular disease was the strongest predictor of late referral (OR 1.40, 95% CI 1.20-1.63, p< 0.001), with median referral timing of only 19 days before death. In contrast, dementia predicted earlier referral (OR 0.74, 95% CI 0.62-0.88, median 55 days before death). Each additional year of age increased odds of late referral (OR 1.01, 95% CI 1.00-1.03, p=0.017). Overall multimorbidity burden did not independently predict timing when specific diagnoses were considered.

Implications: PC referral follows a crisis-driven model, with acute cerebrovascular events triggering late consultations while chronic progressive conditions like dementia enable earlier, trajectory-based referrals. Current systems react to acute deterioration rather than anticipating predictable decline. Systematic redesign should create dual pathways: rapid-response protocols for acute events and proactive monitoring triggers for chronic trajectories.

References: 1. Shih HH, Chang HJ, Huang TW. Effects of Early Palliative Care in Advanced Cancer Patients: A Meta-Analysis. Am J Hosp Palliat Care. Nov 2022;39(11):1350–1357. doi:10.1177/10499091221075570
2. Haroen H, Maulana S, Harun H, et al. The benefits of early palliative care on psychological well-being, functional status, and health-related quality of life among cancer patients and their caregivers: a systematic review and meta-analysis. BMC Palliat Care. Apr 28 2025;24(1):120. doi:10.1186/s12904-025-01737-y
3. Hui D, Heung Y, Bruera E. Timely Palliative Care: Personalizing the Process of Referral. Cancers (Basel). 2022;14(4):1047.
4. Patra L, Ghoshal A, Damani A, Salins N. Cancer palliative care referral: patients' and family caregivers' perspectives - a systematic review. BMJ Support Palliat Care. Nov 3 2022;doi:10.1136/spcare-2022-003990