**4. Candidates and timing for PC referral: meeting patients' needs within the boundary of existential challenges**

According to the current American Society of Clinical Oncology (ASCO) guidelines, patients with advanced cancer (and their caregivers) should be given access to PC services within 8 weeks of diagnosis and while undergoing treatment [1]. However, in reality, such volume of referrals would rapidly overload the existing PC services and further impede care for patients living in places where access to PC is limited. Moreover, there is currently a global lack of PC providers, further hindering the service.

Many attempts have been made to determine acceptable PC referral criteria for patients with cancer [18, 19] due to the misalignment between the number of patients who are eligible for referral and the number of patients who can actually be seen. For instance, Hui et al. employed a panel of 60 experts worldwide and performed a Delphi analysis to establish the major and minor criteria for guiding outpatient PC referrals [20]. Ultimately, 11 major criteria were identified, namely, (1) severe physical symptoms; (2) severe emotional symptoms; (3) requests for hastened death by the patient; (4) spiritual or existential crisis; (5) a need for help with advance planning and decision-making; morbid complications, such as (6) spinal cord compression, (7) brain or leptomeningeal metastases, or (8) delirium; (9) referral requests by the patient; (10) the passing of 3 months since diagnosis with an expected survival time of less than 1 year; and (11) disease progression following second-line therapy [20]. Moreover, 36 minor criteria were identified in cases where 70% of experts reached an agreement. This further emphasizes the difficulty of creating a list of specific criteria.

A recent observational study examined the feasibility of applying these criteria to specific groups of patients with lung cancer [21]. In this study, the previously defined Delphi criteria were reduced to six, namely, (1) severe physical symptoms; (2) emotional symptoms; (3) brain or leptomeningeal metastases; (4) cord compression/ cauda equina; (5) within 3 months of cancer diagnosis and a projected survival time of less than a year; and (6) disease progression after second-line therapy. The findings showed that 82.4% of the 28,164 patients who met the criteria for PC referral based on these indicators obtained PC referral, with a median wait time of 56 days. Thus, the findings of this feasibility study indicate that this condensed list of criteria may be effective if adopted nationally.

#### *Palliative Care for Patients with Lung Cancer: A Review of the Current Developments… DOI: http://dx.doi.org/10.5772/intechopen.106797*

The current guidelines proposed by the National Comprehensive Cancer Network and the American College of Chest Physicians recommend that PC be introduced at an early stage for all patients with metastatic NSCLC [22, 23]. The ASCO also advises that PC is initiated early for patients with advanced malignancies [1]. However, there are no recommendations regarding the timing of PC referral, and few studies have explored the effect of varying time points of early referral. In the study of Bakitas et al. [12], patients with advanced cancer referred for PC at the time of diagnosis and those referred 3 months later had similar scores in the QoL, mood, or use of healthcare resources evaluations. One of the many reasons for providers to delay referrals until symptoms are deemed refractory may be the absence of well-defined guidelines regarding the timing of PC referral. As a result, the time points at which referrals are made are inconsistent, and in many cases, referrals are tardy.

We propose that a compromise position be adopted, one that recognizes realworld workforce issues and the absence of clear guidelines setting out the ideal referral time point yet considers cancer staging at diagnosis, patients' prognosis, and the burden of symptoms. Assuming resources permit, patients with advanced lung cancer should be referred to the PC team within 3 months of diagnosis. This will give the team the opportunity to treat symptoms as they arise and enable the patient and team to build a relationship, which will be invaluable over time as the patient's condition deteriorates. If this is not possible, patients with a high symptom burden should be prioritized regardless of the prognosis. Other patients who should be prioritized for PC referral include those with complex psychosocial stresses, those with an estimated survival prognosis of no more than 1 year, and those with disease progression following first- or second-line treatment. In our opinion, it is critical that healthcare providers have developed primary PC skills, as they will need to fill the inevitable delay between disease diagnosis and PC referral. In particular, it is recommended that healthcare providers working with patients with lung cancer develop their primary PC skills and make efforts to ensure other members of the team are similarly skilled. Symptom assessments used in oncology practices should be standardized yet modified to meet the conditions of the practice and local resources; furthermore, these should incorporate psychosocial stress assessments that can be administered routinely. Using assessments to detect stressors early can advance referrals to case managers or social workers. Similarly, informed by assessment findings, oncology nurses and advanced nurse practitioners can hold timely consultations regarding care goals and future directives. Combined, these measures would promote communication about the care goals and support patients and caregivers in end-of-life settings.
