Novel electronic tool facilitates ICU referrals to palliative care

A novel tool designed by clinicians from The Royal Marsden has facilitated intensive care (ICU) patients to receive earlier access to palliative care. Use of the tool has increased referrals from intensive care unit (ICU) to palliative care by 46%, according to data from its first year of implementation in the hospital1.

The intensive care and palliative care specialist teams at The Royal Marsden discussing ICU Triggers
The intensive care and palliative care specialist teams at The Royal Marsden discussing ICU Triggers

Results on ICU Triggers, an electronic screening tool made up of 122 questions to determine whether ICU patients would benefit from an early palliative care referral, were presented at the virtual European Society for Medical Oncology (ESMO) today (21 September 2021).

Despite a mortality rate of 27-43% for cancer patients admitted to intensive care (ICU), early palliative care involvement is not widely adopted. However, early palliative care input has been demonstrated to improve patient experience and choice, reduce the burden of symptoms and support communication between clinical staff, patients, and their families. It is also associated with a shorter length of stay in ICU and fewer unnecessary medical interventions.

ICU Triggers was co-designed and co-developed by the intensive care and palliative care specialist teams at The Royal Marsden. It was embedded into the ICU’s electronic admission system, with questions designed to determine cancer progression, including signs of severe symptoms, and other indicators where early palliative care would be beneficial, including multi-organ failure. Patients meeting any of these criteria are then referred to the hospital’s palliative care team.

Dr Pascale Gruber, Consultant in Anaesthesia and Intensive Care Medicine at The Royal Marsden, said: “Palliative care provides many benefits for patients and their families, encompassing physical, psychological, and practical support during an incredibly difficult time. This tool proactively identifies patients for early palliative care referral, streamlines this process, and empowers staff and patients to establish agreed treatment goals in keeping with patients wishes in a timely manner. We now hope to see this tool rolled out more widely across the NHS.”

ICU Triggers was a finalist for the End-of-Life Care Initiative of the Year award at the HSJ Patient Safety Awards 2021.


1. The project began in February 2020 and data collection ran until Jan 2021. This includes 8 months of information collected in total due to the project pausing on two occasions due to COVID-19.

2. Healthcare professionals use the tool to check patients for:

I. Multisystem organ failure of three or more systems.
II. Diagnosis of stage 4 cancer.
III. Post-cardiac arrest.
IV. Intracerebral haemorrhage (bleed on the brain) requiring ventilation.
V. ICU admission after hospital stay of ten or more days.
VI. Metastatic cancer progressing after first line treatment.
VII. Graded on the ECOG Performance Status scale – which describes a patient’s level of functioning - as two (able to walk and capable of all selfcare but unable to carry out any work activities) and deteriorating.
VIII. Acute oncology or unplanned admission.
IX. Severe or overwhelming symptoms.
X. Anorexia, hypercalcaemia (increased levels of calcium in the blood), or any effusion (abnormal collection of fluid in hollow spaces or between tissues of the body).
XI. Moderate or severe psychological or existential distress.
XII. Complex social issues.