Patients with advanced chronic respiratory disease carry a greater symptom burden than patients with lung cancer, are less informed about their illness, and are less involved in decisions about it — and they receive far less palliative care, usually only at the very end. Every major respiratory society recommends otherwise. This report describes a model built to close that gap and refined through Plan-Do-Study-Act cycles.
The structure is the transferable part. Referral is triggered by symptom burden, declining respiratory status, frailty, a need to discuss treatment choices, or caregiver strain — none of which require a prognosis. The first consultation is held jointly by a palliative care physician and nurse, and begins by asking what the patient and family understand palliative care to be, which is where most of these referrals fail. It then covers a comprehensive symptom assessment. Follow-up is coordinated by the specialist nurse: symptom review, care coordination, and pharmacological and non-pharmacological management, with advance care planning when the patient wants it.
What makes this implementable outside a well-resourced European service is that the recurring work is nursing work. A single joint consultation establishes the plan; a nurse maintains it. For an Indian respiratory service without a palliative physician on site, that is a model that can be attempted — and the referral triggers can be adopted immediately, whatever service exists to receive them.
- Adopt the referral triggers now: symptom burden, respiratory decline, frailty, treatment decisions, caregiver strain
- Do not make prognosis a requirement for referral
- Open the first consultation by asking what the family thinks palliative care means
- Build follow-up around a specialist nurse rather than repeat physician appointments
- Note this is an implementation description, not a trial of outcomes
Why it matters
It replaces the prognostic threshold that keeps these patients out of palliative care with criteria a respiratory clinic can actually apply.
Don't overread it
This describes a service model refined through quality improvement cycles; it reports no comparative outcome data of its own.
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