Early Referral to Palliative Care in Advanced Gastrointestinal Cancers

November 2019 Vol 10, No 11
Annie Nelson, MSN, CNL
Sanford USD Medical Center,
Sioux Falls, SD
Jill Waggoner, DNP, APRN-CNP
Sanford USD Medical Center,
Sioux Falls, SD
Kelly Carlson, MHA, BSN
Sanford USD Medical Center,
Sioux Falls, SD
Amber Allen, BSN, OCN
Sanford USD Medical Center,
Sioux Falls, SD
Gwen Reker, MSN, RN
Sanford USD Medical Center,
Sioux Falls, SD
Sandi Froke, BSN, OCN
Sanford USD Medical Center,
Sioux Falls, SD
Danielle McClennen, BSN, OCN
Sanford USD Medical Center,
Sioux Falls, SD
Jon Bleeker, MD
Sanford USD Medical Center,
Sioux Falls, SD

Background: Advanced gastrointestinal (GI) cancers carry high mortality rates and symptom burdens. The Oncology Nursing Society and the American Society of Clinical Oncology have both released position statements calling for palliative care referrals at the time of cancer diagnosis. At Sanford Medical Center in 2017 and 2018, only 35% of patients diagnosed with GI cancers received palliative care referrals. Among the 35% of patients receiving referrals, most (85%) referrals occurred in the inpatient hospital setting and near the end of life (average 99 days from diagnosis). The GI oncology nurse navigator identified the need to increase the percentage of palliative care referrals in the advanced GI cancer population and expedite the timeliness of such referrals.

Objectives: For the target population, during a 1-year period (January 2019-December 2019), specific objectives are as follows:

  • 80% of patients receive palliative care referrals
    • 50% or more of these referrals occur in the outpatient clinic (vs inpatient setting)
    • Palliative care referral within 8 weeks of diagnosis
  • Increase the percentage of patients who validate or complete advanced care planning documents within 1 month of the palliative care visit


  • Nurse navigator identified an opportunity for early integration of palliative care services in the target population
  • Oncology clinic leadership formed a multidisciplinary team with key stakeholders—nurse navigation, palliative care, triage nursing, cancer center leadership, clinical informatics, and provider champions
  • Stakeholder team applied for and received competitive grant funding through the National Institutes of Health
  • Stakeholder team created and implemented workflow identifying and pursuing referral of patients to palliative care in a timely manner
  • Educated providers and clinic staff
  • Created data collection tool for ongoing monitoring of progress toward identified goals


  • 1st quarter data (January 1, 2019-March 31, 2019)
    • 35 patients newly diagnosed with incurable or advanced GI malignancies (esophageal, gastric, pancreatic, hepatobiliary, colorectal cancers)
    • 65.7% of eligible patients received referral to palliative care (previously 35%)
    • Mean length of time from diagnosis to referral decreased to 13.5 days (previously 99 days)
    • Percentage of referrals completed in the outpatient (vs inpatient) setting increased to 67% (previously 15%)
    • Validation or completion of advanced care planning documents as a result of the palliative care visit is 100%
    • 2nd and 3rd quarter data will be available by October 15, 2019

Conclusion: A workflow was designed to identify and refer patients with advanced GI tract cancers to palliative care. Utilization of this new workflow has improved the timeliness of and patient enlistment in palliative care. All patients attending a palliative care consultation have completed crucial advanced care planning documents. The program strives to dispel the myth that palliative care is synonymous with hospice and has been instrumental in changing clinic culture toward acceptance of this invaluable patient resource.


  1. Oncology Nursing Society. Palliative Care for People With Cancer. www.ons.org/sites/default/files/2017-06/Palliative%20Care.pdf. 2017.
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