Table 7 Key point recommendations in relation to the IPC criteria provides the key recommendations of Integrated Palliative Care of the included guidelines and pathways

Discussion of illness limitations and prognosis

[22–28, 30–35, 38, 39]

“Open communication between patient and doctor.”

Holistic assessment

[22, 23, 25, 26, 28–30, 33–35, 38–40]

“Address physical, emotional, social and spiritual needs.”

Timing for holistic assessments

[23, 27, 28, 31, 33–35, 38, 39]

“Work closely with clinicians to agree on the indicators for the exact timing of the holistic assessments.”

Timing for PC introduction

[22–26, 28, 31–35, 38, 39]

“Early integration of PC in the disease trajectory.”

Patient’s goals assessments

[22–28, 30, 33, 34, 39, 40]

“Disease specific management plans and care plans should be based around patient’s personal goals.”

Continuous goal adjustment

[22, 24, 28, 31, 33, 34, 38, 39]

“Regular assessment of patients’ PC needs and continuous communication and collaboration between care teams and organizations.”

Suffering reduction

[22–29, 31–41]

“Timely access to symptom control and administration of appropriate medication”

Advance care planning (ACP)

[22, 23, 28, 30, 31, 33–35, 38–40]

“Early discussion of ACP, including patients’ end-of-life needs and preferences.”

Involvement of PC team

[22, 23, 25, 26, 28–31, 33–36, 38, 40]

“Specialist PC is provided by multi-professional PC teams, including physicians, nurse specialists, psychologists, chaplains, social workers, pharmacists and other appropriate allied health professionals.”

Recommendations on care during the last hours of living

[22, 25, 28, 34, 35, 37, 40]

“Care in the last days of life should be available 24 h a day, including rapid access services, symptom control and assessment of end-of-life preferences.”

Grief and bereavement care recommendations

[33–35, 40]

“Provide family bereavement support and ensure there is access to spiritual care and chaplaincy services.”