Results:

The Delphi panel consisted of experts ranging in age from 30-69 years old with a median of 15 years (interquartile range, 10-25 years) experience in cardiology and 11 years (7.5-19 years) experience in palliative care. Response rates in the first, second, and third rounds were 96%, 89%, and 93%, respectively. The consensus definition of advanced heart failure was New York Heart Association-functional class (NYHA-FC) III, NYHA-FC IV, and American College of Cardiology/American Heart Association (ACC/AHA) advanced stage D heart failure.

By round 3, consensus on 25 major criteria for specialist palliative care referral was obtained. These included 14 disease-based, 10 needs-based, and one time-based criteria ranging across six topics: advanced/refractory heart failure, comorbidities, and complications, advanced heart failure therapies, hospital utilization, prognostic estimate, symptom burden distress, and decision-making support. Disease-based criteria included markers of severe disease such as disease progression, inability to tolerate guideline-directed therapies, advanced cardiac therapies, comorbidities, complications, and hospital utilization (≥2 emergency room visits or hospitalizations within the past 3 months). Needs-based criteria included symptom burden and patient or caregiver supportive care concerns. The time-based criterion was clinician-estimated life expectancy of ≤6 months. Expert panelists strongly rated the major criteria as being clearly stated, objective in nature, able to be assessed accurately, easily incorporated into routine screening in the primary or cardiology practice setting, and may be useful in facilitating specialist palliative care referral at their own institutions.