Advanced heart failure patients need a lot of supportive care. Although it is not always apparent who should be referred for specialist palliative care and when, but it can be helpful. In order to establish consensus referral standards for expert palliative care for patients with advanced heart failure, researchers performed a Delphi survey of international specialists.

Over the course of 3 rounds, clinicians with experience integrating cardiology and palliative care from 5 different continents were asked to score 34 disease-based, 24 need-based, and 9 time-based criteria. A priori, consensus was established as an agreement of ≥70%. If the experts agreed that satisfying the criterion alone was enough to support a referral, the criterion was marked as significant.

The response rate was 44 of 46 (96%) in the first round, 41 of 46 (89%) in the second round, and 43 of 46 (93%) in the third round. About 25 important criteria for referral to specialized palliative care were agreed upon by the panel. The 25 major criteria were divided into 6 categories, including “advanced/refractory heart failure, comorbidities, and complications” (e.g., cardiac cachexia, cardiorenal syndrome) (n = 8), “advanced heart failure therapies” (e.g., chronic inotropes, precardiac transplant) (n = 4), “hospital utilization” (e.g.,  emergency room visits, hospitalization) (n = 2), “prognostic estimate” (n = 1), “symptom burden/distress” (eg, severe physical/emotional/spiritual distress) (n = 6), and “decision making/social support” (eg, goals-of-care discussions) (n = 4). Around ≥90% agreement was reached on the majority (68%) of the important criteria.

International specialists came to an agreement on a wide range of referral standards for specialized palliative care. These criteria may be helpful for standardizing palliative care access in the hospital and/or outpatient settings with additional validation.