The development of local outpatient palliative care referral criteria for persons with advanced cancer at the University Hospital Centre Zagreb: a Delphi study.

BACKGROUND

Despite recommendations for early integration, persons with cancer in Croatia are often referred to palliative care late in their disease course. This study aimed to develop standardized local referral criteria to facilitate earlier palliative care referral at University Hospital Centre Zagreb (UHC Zagreb).

METHODS

We conducted a mixed-methods consensus process comprising two Delphi survey rounds with oncologists at UHC Zagreb, a facilitated consensus meeting to refine criteria, and a confirmatory survey. The initial item set drew on the Hui international consensus criteria and the Royal Marsden Hospital Trigger Tool. In both Delphi rounds, participants rated each criterion on a 9-point scale. Consensus was predefined as ≥ 70% rating 7-9. Quantitative data were summarised descriptively. Qualitative data were analysed using the content analysis method.

RESULTS

37 oncologists participated. Of the initial 17 criteria, 10 met the Delphi consensus threshold. The consensus meeting accepted one criterion unchanged, rejected four, combined four overlapping psychosocial items, and revised eight for clarity and local applicability. The confirmatory survey endorsed a 10-item set: (1) symptomatic brain/leptomeningeal metastases or CNS tumour; (2) ECOG 2 and deteriorating; (3) patient request or when no further oncologic options remain; (4) severe physical symptom(s); (5) symptomatic spinal cord compression/cauda equina; (6) advanced/incurable cancer with estimated prognosis ≤ 1 year; (7) complicated social situation impacting treatment; (8) delirium related to cancer; (9) moderate-severe psychological/existential distress; and (10) frequent unplanned admissions or emergency visits.

CONCLUSIONS

We have developed local referral criteria to standardise and accelerate outpatient palliative care referrals at UHC Zagreb. Implementation and prospective evaluation should assess fidelity, timeliness, patient-reported outcomes, utilisation, and costs.