The pressing need to identify patients who would benefit from palliative care early in their illness trajectory is a significant challenge in healthcare. This article delves into whether there are validated tools available to effectively increase palliative care referrals, with a specific focus on the Supportive and Palliative Care Indicators Tool (SPICT™).
How SPICT™ Aids Advance Care Planning Conversations
Research indicates that the SPICT™ tool can be instrumental in facilitating crucial conversations about advance care planning between clinicians and patients. It serves as a structured framework, offering a proforma that covers essential aspects of end-of-life care. This framework not only guides end-of-life discussions but also establishes a common language for enhanced collaboration within multidisciplinary healthcare teams.
Figure 1: Literature Review Process for Palliative Care Referral Tools. A flow diagram illustrates the systematic approach used to identify relevant studies, detailing the number of records at each stage: retrieved, screened, excluded, and ultimately included in the review.
For instance, a prospective feasibility study examining the practical application of SPICT™ demonstrated a notable increase in palliative care planning. In this study, general practitioners (GPs) received training on the German version of SPICT™ (SPICT-DE™). Over a two-month intervention, they utilized the tool with adult patients diagnosed with life-limiting illnesses. Follow-ups at six months revealed that GPs’ actions, guided by SPICT-DE™ recommendations, were largely appropriate. The most common actions included agreeing on current and future care plans with patients and families (75%), reviewing and optimizing treatment and medication (67%), and planning for potential loss of decision-making capacity (62%). Notably, considering specialist palliative care referral for complex symptom management was deemed appropriate for 32% of patients. The impact of SPICT™ was further confirmed at the 6-month follow-up, with significant actions initiated in medication review (46%) and advance care planning (37%).
Further research by Afshar et al. among German GPs highlighted the tool’s supportive role in communication and care coordination. GPs felt SPICT™ broadened their understanding of patient needs, especially for those with non-cancer diagnoses. More than half of the patients in this study had their agreed care plans initiated by the 6-month mark. While some experienced GPs felt the tool didn’t alter their practice, a significant majority (over two-thirds) envisioned using SPICT-DE™ in their routine practice.
Studies also show that nurses trained in SPICT™ experienced increased confidence in identifying patients nearing end-of-life and in initiating advance care planning discussions. In a renal ward study, nurses used SPICT™ to screen patients upon admission, identifying those nearing end-of-life. A ‘SPICT™ positive’ alert on patient lists prompted physician and multidisciplinary team reviews. Sixteen percent of new admissions were flagged as ‘SPICT™ positive’, all of whom received palliative care consultations and were discharged with advance care directives and resuscitation plans. Nurses reported a significant improvement in their ability to recognize patients approaching end-of-life.
Similarly, a clinical improvement project in a long-term acute care facility’s cardiopulmonary unit, focused on enhancing palliative care screening and consultation using SPICT™, showed high screening rates, end-of-life conversations, and referrals. Nurses trained in SPICT™ screened all new admissions, with 96% being ‘SPICT™ positive’. While initial palliative care consultation rates within a week were lower (7 patients), all of these patients received resuscitation plans and advance directives. Crucially, SPICT™ implementation doubled the facility’s monthly palliative care referrals, from 32 to 84. Another project in ambulatory care settings revealed nurse practitioners found SPICT™ valuable for initiating palliative care discussions and determining patient eligibility, resulting in a significant increase in palliative care referrals from 16% to 50%.
Validation studies of SPICT™ in Danish (SPICT-DK™) and Swedish (SPICT-SE™) through focus groups with healthcare professionals reported positive feedback. They described SPICT™ as a valuable linguistic tool, providing a shared language for collaboration and focused patient care. Nurses and doctors emphasized the tool’s specificity in aiding their practice.
However, not all feedback was universally positive. An expert committee adapting SPICT™ for Japanese use expressed concerns about its appropriateness in a culture where ‘not-telling the truth’ is common and healthcare is highly specialized, potentially fragmenting care planning.
Global Use of SPICT™ Across Diverse Settings
SPICT™ has been implemented across a wide range of patient groups, healthcare settings, and countries to identify palliative care needs. These populations include individuals over 65, those with advanced cancer, and patients with chronic conditions such as cardiovascular, renal, and pulmonary diseases.
The tool has been utilized in various settings, with ten studies conducted in primary care and general practice. Other settings include outpatient clinics, residential aged care facilities, and even community households in India. Originally designed for hospitals, though not formally validated in that setting initially, SPICT™’s versatility is evident in its broad application. Table 1 (from the original article, not included here for brevity but readily available in the source document) provides a comprehensive list of contexts where SPICT™ has been employed.
Geographically, studies featuring SPICT™ are diverse. Ten studies originated from European countries, seven from Asia, three from the USA, two from Australia, and one each from South Africa, Chile, and Peru. A review paper also came from Switzerland. Interestingly, a systematic review and survey of European primary care practices indicated that, at the time, the United Kingdom was unique in Europe for incorporating SPICT™ into clinical guidelines for palliative care identification in both primary and secondary care.
Languages of Validated SPICT™ Versions
SPICT™ has undergone rigorous translation, cross-cultural adaptation, and validation to ensure its effectiveness across different linguistic and cultural contexts. Validated versions exist in Danish and German, developed using the TRAPD model. Further validation of SPICT-DE™ in German general practice with patient cohorts has been conducted. Additionally, SPICT™ has been translated and adapted into Italian (SPICT-IT™), Spanish (SPICT-ES™), Swedish, and Japanese (SPICT-J™) using the Beaton protocol for cross-cultural adaptation of health measures. Studies have confirmed the reliability and validity of SPICT-ES™ and SPICT-J™ after cultural adaptation, with nurses reporting positive experiences regarding feasibility. An Indonesian version also demonstrated high reliability and validity in identifying unmet palliative care needs in hospital patients.
For low-resource settings, SPICT™ has been adapted and translated for use in Thailand (SPICT-LIS™). The Thai version showed high interrater reliability when used by nurses and GPs in case vignettes. A Delphi study informed the development of SPICT™ for South Africa (SPICT-SA™), with modifications to include conditions like hematological and infectious diseases and trauma, though validation in these areas is still pending. While not a validation study, research comparing the Dutch version (SPICT-NL™) to the Surprise Question (SQ) in general practice found SPICT™ superior in identifying palliative care needs, particularly in younger individuals.
SPICT4-ALL™, a simplified version for family, friends, and care staff, is available in English, German, Danish, and Spanish on the SPICT™ website. While successfully used in rural Indian communities, formal validation studies for SPICT4-ALL™ are currently lacking.
SPICT™ and Documented Goals of Care
Evidence suggests that SPICT™ facilitates changes in documented goals of care by prompting end-of-life discussions. A pre-post intervention study involving German GPs trained in palliative care and SPICT-DE™ showed improved documentation after SPICT™ implementation alongside a public awareness campaign. Care planning documentation increased from 33% to 51%, documented preferred place of death rose from 20% to 33%, and documentation of patient wishes and spiritual beliefs increased from 18% to 27%. GPs also reported improved self-perceived quality of end-of-life care.
In an Australian aged care facility study comparing SPICT™ and SQ, residents screened SQ+ were further assessed with SPICT™. All SQ+ residents showed end-of-life indicators on SPICT™. Among these, 49% received palliative care. A high percentage had GP management plans (97%), advance care directives (67%), and had discussed treatment options (67%). However, the study design didn’t definitively establish a causal link between SPICT™ and changes in care planning documentation.
Conclusion
The evidence reviewed suggests that the SPICT™ tool is a validated and effective instrument for increasing palliative care referrals across various healthcare settings and patient populations. Its structured approach aids clinicians in identifying patients who would benefit from palliative care, facilitates essential conversations about advance care planning, and promotes better documentation of patient goals of care. While cultural adaptations and ongoing validations are crucial, SPICT™ stands out as a valuable tool for improving access to palliative care and enhancing end-of-life care experiences.
