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Acute Events Drive Late Palliative Care Referrals: Diagnosis-Specific Timing Patterns in Older Adults
Abstract   Peer reviewed

Acute Events Drive Late Palliative Care Referrals: Diagnosis-Specific Timing Patterns in Older Adults

Alaa Albashayreh, Carolina Gustafson, Yuya Hagiwara, William Zeitler and Stephanie Gilbertson-White
Journal of pain and symptom management, Vol.71(6), pp.e833-e834
06/2026
DOI: 10.1016/j.jpainsymman.2026.04.097

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Abstract

Background While early palliative care (PC) improves outcomes [1, 2], real-world referral timing often appears reactive and crisis-driven rather than proactive [3, 4]. Objectives To identify diagnosis-specific patterns in PC referral timing, with focus on distinguishing acute event triggers from chronic condition trajectories. Methods Retrospective cohort study of 3,349 older adult decedents (age ≥65) who received PC at a large academic medical center (2010-2023). Primary outcome was late PC referral (≤30 days before death). We used multivariable logistic regression to identify independent predictors of late referral, adjusting for demographics and individual chronic conditions. Multimorbidity burden was quantified as the total count of 10 common chronic conditions (hypertension, hyperlipidemia, diabetes, COPD, dementia, cancer, coronary heart disease, cerebrovascular disease, arthritis, congestive heart failure) identified via ICD codes. Results The cohort had a mean age at death of 75.1±6.0 years, was 54.5% male and 94.5% White, with a mean of 4.5±2.1 chronic conditions. PC was initiated profoundly late, with a median of just 25 days before death (IQR 8-96) and a majority of patients (54.4%) receiving a late referral. Cerebrovascular disease was the strongest predictor of late referral (OR 1.40, 95% CI 1.20-1.63, p< 0.001), with median referral timing of only 19 days before death. In contrast, dementia predicted earlier referral (OR 0.74, 95% CI 0.62-0.88, median 55 days before death). Each additional year of age increased odds of late referral (OR 1.01, 95% CI 1.00-1.03, p=0.017). Overall multimorbidity burden did not independently predict timing when specific diagnoses were considered. Implications PC referral follows a crisis-driven model, with acute cerebrovascular events triggering late consultations while chronic progressive conditions like dementia enable earlier, trajectory-based referrals. Current systems react to acute deterioration rather than anticipating predictable decline. Systematic redesign should create dual pathways: rapid-response protocols for acute events and proactive monitoring triggers for chronic trajectories.

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