The Catalan Institute of Oncology (ICO) Presents the ICO Toolkit-2: An Updated,Spanish National Assessment Kit for Patients with Malignant Neoplasm in Palliative Care

Abstract

Introduction:

The needs of patients living with malignant neoplasm, and those of their families and care partners, require a multidimensional and interdisciplinary approach. By systematically assessing these needs with validated tools, healthcare professionals can identify and monitor therapeutic objectives, interventions, and results.

Objective:

At the Catalan Institute of Oncology (ICO), we set out to update the ICO Toolkit—a set of instruments for assessing the physical, emotional, and social needs of palliative care patients.

Methods:

We conducted a non-systematic review of the most common instruments currently used for multidimensional assessment of cancer patients nearing the end of life and then applied the Delphi method to achieve consensus on the instruments to be included in the updated ICO Toolkit-2. Initial consensus was obtained via interobserver agreement within a discussion group of experts, drawing on their daily clinical practice, and the published evidence. The Delphi method was then used to survey a representative sample of 22 experts from the ICO’s three interdisciplinary palliative care teams.

Results:

The final 19 instruments selected for the ICO Toolkit-2 achieved a degree of consensus of 90%–100%.

Conclusions:

The updated ICO Toolkit-2 facilitates a multidimensional, systematic, objective, and measurable assessment of the needs of malignant neoplasm patients throughout their cancer journey. Uptake of the new toolkit could improve the care and support provided to patients and their families and care partners.

Introduction

Palliative care is an acknowledged part of cancer control. It goes beyond prevention or cure to ensure the needs of all patients are met and has evolved from an end-of-life focus to improve quality of life across the cancer continuum.¹ Cancer remains deadly—for every new case of cancer, there are half as many deaths—but treatment breakthroughs continue to lower the risk of mortality and improve long-term survival.^2–6 Palliative care is therefore essential in cancer care: Patients will live longer and have complex needs.

Accurate and early assessment is central to successfully addressing the problems and concerns that underlie patients’ needs.⁵ Moreover, palliative care intervention has proven benefits for symptom control and survival.^7–9 Specific assessment instruments for different symptoms can improve detection and outcomes, such as in the case of pain or depression.^10,11 Such instruments can enable the various professionals and teams involved in patient care to share objective and reliable information at all stages.¹² Unfortunately, palliative care assessments are often neither systematic nor comprehensive, suggesting that clinicians may choose not to use the instruments or not be aware of them.^11,13 To bridge this gap, in 2010 we designed a set of instruments at the Catalan Institute of Oncology (ICO) for the multidimensional assessment of patients with advanced cancer.¹⁴ We named this set of instruments the ICO Toolkit.

ICO treats 45% of the cancer population in Catalonia, Spain. The interdisciplinary team, comprising three palliative care services, takes a comprehensive approach to treating cancer patients and supporting their families and care partners. As a result, ICO became an ESMO Designated Center of Integrated Oncology & Palliative Careⁱ in 2007 and has since been reaccredited (currently valid until 2025). The original ICO Toolkit, published in 2010, was developed via a consensus process involving professionals from three of ICO’s main centers.¹⁴ The kit included assessment instruments as well as specific questions that clinicians found most useful in palliative care assessments. It enabled clinicians to assess patients’ physical, psychological, and social symptoms and their needs.

Twelve years later, we have access to new instruments and new knowledge on the complex needs of palliative care patients living with advanced cancer. We have therefore updated the original kit with additional instruments and assessment domains (e.g., existential) to keep step with developments in the field.

By promoting best practices that draw on cancer treatment innovations, healthcare professionals can help meet the emerging needs of advanced cancer patients. This paper outlines the degree of consensus for the instruments in the updated ICO Toolkit-2, all of which facilitate a relevant, systematic, and comprehensive palliative care assessment. Moreover, our recommendations and their justifications provide a single point of reference for clinicians nationally and in the wider medical community.

Aim

To update the ICO Toolkit—a set of instruments for assessing the physical, emotional, and social needs of palliative care patients—and ensure palliative care clinicians in Spain, and in the wider medical community, are empowered to conduct a systematic and multidimensional assessment of the needs of malignant neoplasm patients and those of their families and care partners. Though our paper looks at palliative care in Spain specifically, multidisciplinary palliative care assessments are similar in all settings, and the ICO Toolkit-2 is therefore relevant to all professionals in this field, irrespective of their geographical location.

Target population

The ICO Toolkit-2 provides evidence-based recommendations for validated tools that interdisciplinary palliative care providers can use to address the needs of patients with malignant neoplasms and those of their families and care partners.

Design

Developing the recommendations

From March to October 2021, ICO conducted a non-systematic review of the most common instruments and scales for multidimensional palliative care assessments. Our findings informed the design of the new version of our toolkit: the ICO Toolkit-2. The draft updated toolkit was sent to our panel of experts for their consideration, and the agreed-upon tools were further supported with the evidence-based recommendations outlined in this paper.

Since our study did not involve patients, Institutional Review Board (IRB) approval was neither sought nor required.

Panel selection and composition

All members of the palliative care teams in ICO’s three main centers were invited to participate.

Approximately 4 weeks prior to the distribution of the Delphi survey, an invitation e-mail was sent to all potential participants outlining the objectives of the study. Any participant who actively declined at this stage was removed from future correspondence.

We then issued our survey via Google Forms (this free, open-source survey software ensures anonymous participation). Before completing the survey, recipients were informed that their decision to participate would be interpreted as informed consent.

Our selection criteria required that participants be healthcare professionals in the interdisciplinary palliative care team in any branch of the Catalan ICO. They must provide clinical palliative care to cancer patients and their families and care partners, hold the relevant knowledge and experience, and be willing to participate.

The research team is responsible for data confidentiality and will safely store the data for 5 years after publication of the results.

The final panel comprised 12 palliative care physicians, 6 nurses, 3 psycho-oncologists, and 3 social workers. Two of the psycho-oncologists hold a PhD, and the other holds a master’s degree. Medical professionals with a master’s degree in palliative medicine were considered specialists in this area.ⁱⁱ

Delphi method

We applied the Delphi method to achieve consensus on the candidate instruments for the updated ICO Toolkit-2. We recommended 19 validated instruments to our experts in the first survey round. We asked two questions: the first gauged the degree of consensus [using a seven-point scale from 1 (strongly disagree) to 7 (totally agree)] on the clinical relevance of the instrument for assessing a specific domain or symptom (e.g., the CAGE Test to detect alcohol-related disorders in adults); the second allowed the experts to make additional comments.

A subsequent round provided summary feedback to participants on the average response to each question, as well as each panelist’s specific response. In accordance with the Delphi method, only those questions that did not achieve consensus in the first round were submitted for further response.

The following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)-type flowchart outlines our process:

Results

Delphi method results

In the first round, the questionnaire was answered by 22 of the 24 invited panelists, comprising 6 men and 18 women in age brackets of 30–40 years (25%), 40–50 years (50%), or over 50 years (25%). One panelist had fewer than 5 years’ experience in palliative care, while almost three quarters of panellists had more than 10 years’ experience. Figures 1 and 2 provide further details on the participants’ disciplines and professional experience.

FIG. 1.

Delphi participants’ disciplines.

FIG. 2.

Delphi participants’ professional experience.

Of the 19 tools recommended initially, 15 achieved strong consensus while 4 achieved an intermediate degree of consensus.

In the second round, the questionnaire was answered by 16 panelists and only included the four recommendations that did not achieve strong consensus in the first round. Three of these attracted strong consensus in the second round while the other maintained an intermediate degree of consensus. The results of the first and second rounds of the Delphi method are presented in Figures 3 and 4, respectively. Figure 5 shows the final results of the Delphi method.

FIG. 3.

Delphi first round results.

FIG. 4.

Delphi second round results.

FIG. 5.

Delphi final results. *The score was assessed on a scale from 0 to 7, where 0–1 = totally disagree, 2–3 = disagree, 4–5 = somewhat agree (intermediate), 6 = strongly agree, and 7 = totally agree. **ESAS, Edmonton Symptom Assessment System; QoL: quality of life; DME: Emotional Disorder Detection. Questionnaire; WTHD: wish to hasten death; CAM: Confusion Assessment Method; GES: Grupo Espiritualidad de la SECPAL-Scale developed by the Spirituality Group of the Spanish Palliative Care Society; ECOG PS: Eastern Cooperative Oncology. Group Performance Status; PPS: Palliative Performance Scale; ECS-CP: Edmonton Classification System. for Cancer Pain; ACP: advanced care planning; NIT: diagnostic and therapeutic intervention levels. The following instruments were not part of the original toolkit: Braden Scale, DME, WTHD, RamsayScale, ACP, NIT.

We will now outline the tools contained in the updated ICO Toolkit-2, including the degree of consensus and justification for each recommendation.

Recommendations: the ICO toolkit-2

The recommendations that follow make up the ICO Toolkit-2. We have grouped the recommendations in a way we feel best supports healthcare teams in assessing patients, starting with the physical dimension before addressing emotional, cognitive, and spiritual needs. This is the order typically used when taking the patient’s history.

Some specific assessment stages contain multiple recommendations. For example, Sign and Symptom Assessment comprises four recommendations: a more generalized screening instrument is recommended first, followed by instruments with a narrower focus. The three recommendations under Functional Assessment follow the typical order in which the tools are used in clinical practice at the Catalan ICO, for example.

Healthcare professionals should feel free to approach the recommendations in a different order if doing so would better serve the needs of their patients. While the conversation with the patient may lead them in one direction or another, referring back to the toolkit will help ensure that the assessment is systematic and that all needs are addressed.

Antecedents assessment

Recommendation 1: Use the CAGE (Cut, Annoyed, Guiltyi Eye-opener) Test to screen for alcohol addiction.¹⁵

Degree of consensus: Strongly agree (1st round agreement 5.86; 2nd round agreement 6.19). The question was modified from “detect addictions” in the 1st round to “detect alcohol addiction” in the 2nd round, following comments by the experts.

Justification for recommendation 1: The CAGE Test screens for alcohol abuse.¹⁵ A 2007 review analyzed the reliability and validity of the CAGE Test across different patient populations, demonstrating that it “had high test-retest reliability (0.80–0.95), and adequate correlations (0.48–0.70) with other screening instruments.”¹⁶ A separate meta-analysis of 22 studies reported that the questionnaire’s mean internal consistency was α = 0.74.¹⁷ Dhalla et al. found that “the questionnaire is a valid tool for detecting alcohol abuse and dependence in medical and surgical inpatients, ambulatory medical patients, and psychiatric inpatients (average sensitivity 0.71, specificity 0.90),” but it should not be used to detect less serious drinking problems. The authors of the review concluded that “CAGE is short, feasible to use, and easily applied in clinical practice,” but stress its limitations and urge that a positive screen be subject to subsequent diagnostic assessments.¹⁶

Symptom and sign assessment

Recommendation 2: Use the Edmonton Symptom Assessment System (ESAS) for the most common symptoms of advanced cancer.¹⁸

Degree of consensus: Strongly agree (1st round agreement 6.73).

Recommendation 3: Use the wellbeing item in the ESAS as an indirect indicator of quality of life to avoid the need for an additional, specific questionnaire.

Degree of consensus: Strongly agree (1st round agreement 5.68; 2nd round agreement 6.13). The question was modified from “to indirectly assess quality of life to avoid using a specific tool” in the 1st round to “indirectly assess quality of life to avoid using a specific tool, in order to reduce the burden of the clinical visit” in the 2nd round, following comments by the experts.

Justification for recommendations 2 and 3: ESAS is a group of 10 visual analogue scales for assessing nine common symptoms (pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, depression, anxiety, well-being) and other symptoms specific to the patient. ESAS proved to be an appropriate instrument when tested on advanced cancer patients in Spain.¹⁹ Most patients were able to complete the questionnaire with a health professional for support and agreed with the item order. Patients stressed that the “now” was important. In other words, the questionnaire time frame should not be misinterpreted.²⁰

Recommendation 4: Use the Bristol Stool Chart to assess stool quality.²¹

Degree of consensus: Strongly agree (1st round agreement 6.18).

Justification for recommendation 4: The Bristol Stool Chart is a visual classification system with seven stool types. In 1997, Lewis and Heaton assessed the usefulness of the scale for monitoring changes in gut transit time. Their study measured the change in the entire intestinal transit time in 66 volunteers, concluding that scales such as the Bristol Stool Chart are appropriate for tracking bowel function changes and can be used in clinical practice and research.²¹

Recommendation 5: Use the Braden Scale to assess the risk of pressure ulcers.²²

Degree of consensus: Intermediate degree of consensus (1st round agreement 5.32; 2nd round agreement 5.69). The question was modified from “to assess the risk of pressure ulcers” in the 1st round to “assess the risk of pressure ulcers using six specific parameters” in the 2nd round, following comments by the experts.

Justification for recommendation 5: The Braden Scale assesses the risk of a patient developing a pressure ulcer. The six subscales—sensory perception, moisture, activity, mobility, nutrition, and friction/shear—are scored from 1 to 4 to provide an initial assessment of a patient’s specific circumstances. It can guide healthcare providers to the types of further assessment and interventions that may be needed. Lower subscale and total scores indicate the need for greater nursing intervention.²³

Functional assessment

Recommendation 6: Use the Barthel Index to measure how well patients can perform the basic activities of daily living.²⁴

Degree of consensus: Strongly agree (1st round agreement 6.64).

Justification for recommendation 6: The Barthel Index measures patients’ ability to perform 10 basic activities of daily living [feeding, bathing, dressing, grooming, controlling bowels, controlling bladder, toilet use, transfers (bed to chair and back), mobility on level surfaces, and stairs].²⁴ An audit of the Barthel Index in palliative care concluded that it could reduce hospital admissions and therefore help honor the wishes of patients who wish to die at home. It can also support hospital discharge planning and help ensure patients receive care in a place of their choosing.²⁵ Another study calculated the mean change in weekly Barthel scores to gauge changes in patients’ physical function. Changes in Barthel Index scores were more important indicators of survival than isolated scores for terminally ill patients admitted to palliative care.²⁶

Recommendation 7: Use the Eastern Cooperative Oncology Group Performance Status (ECOG PS) scale to assess the impact of advanced cancer on patients’ daily activities.²⁷

Degree of consensus: Strongly agree (1st round agreement 6.05).

Recommendation 8: Use the Palliative Performance Scale (PPS) to measure the functional impairment of a patient with palliative care needs.²⁸

Degree of consensus: Strongly agree (1st round agreement 6.64).

Justification for recommendations 7 and 8: A functional assessment supports clinical information by defining the impact of a disease on patient autonomy.^29,30 This is important for cancer patients because it provides information on survival prognosis and quality of life, supports decision-making, aids the choice of therapies, and helps define patients’ individual needs.³⁰

The ECOG PS Scale assesses changes in the patient’s ability to perform the activities of daily living, with scores ranging from 0 (fully active) to 5 (dead).^27,31

The PPS measures the functional impairment of a palliative care patient across five domains: ambulation, activity level and evidence of disease, self-care, intake, and level of consciousness.²⁸

Though the available scales were developed with different objectives, they are equally valid and reliable and may be used interchangeably.^30–33

Emotional assessment

Recommendation 9: Use the Emotional Disorder Detection Questionnaire to screen for emotional distress.³⁴

Degree of consensus: Strongly agree (1st round agreement 6.41).

Justification for recommendation 9: The Emotional Disorder Detection Questionnaire, developed in Spanish, is an emotional distress screening tool (24) comprising three questions addressed to the patient plus observation by the healthcare provider. The questionnaire yields a total score between 0 and 20. Statistical analysis suggests that a cut-off score of ≥9 results in sensitivity and specificity greater than 75%.³⁵

Recommendation 10: Use the Endicott substitution criteria as a diagnostic tool for depressive syndrome in the patients with malignant neoplasm.³⁶

Degree of consensus: Strongly agree (1st round agreement 6.18).

Justification for recommendation 10: The Endicott substitution criteria are a diagnostic tool for major depressive disorder in cancer patients.³⁶ A 2013 review of the existing diagnostic criteria concluded that one of the three original studies supported the use of substitute criteria (Endicott criteria).³⁷ The Endicott criteria should be applied if the Emotional Disorder Detection Questionnaire (Recommendation 6) identifies emotional distress. In such cases it would be helpful to consult a psycho-oncologist or psychiatrist.

Recommendation 11: Acknowledge the wish to hasten death (WTHD) in the emotional assessment of advanced cancer patients, depending on the individual patient’s needs and not routinely, and in line with the natural progression of the conversation with the patient.

Degree of consensus: Strongly agree (1st round agreement 6.09).

Justification for recommendation 11: Patients nearing the end of life may communicate a WTHD. A recent systematic review and meta-ethnography identified five themes: “suffering (overarching theme), reasons for and meanings and functions of the WTHD and the experience of a timeline towards dying and death”.³⁸ The various factors implicated in the patient’s suffering erode their “sense of self, of dignity and meaning in life” and contribute to the WTHD. Since WTHD means something different to each patient, a holistic understanding is important when creating and implementing patient-centred care plans.³⁸

Cognitive assessment

Recommendation 12: Use the Confusion Assessment Method (CAM) (29) to diagnose delirium.³⁹

Degree of consensus: Strongly agree (1st round agreement 6.59).

Justification for recommendation 12: Delirium is a serious neuropsychiatric disorder that has a major impact not just on patients but on their families.⁴⁰ Sadly, it often goes undiagnosed. CAM is an appropriate tool for screening palliative care patients for delirium, but healthcare providers must be sufficiently trained in its use.⁴¹

Recommendation 13: Use the Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) to screen for cognitive impairment.⁴²

Degree of consensus: Strongly agree (1st round agreement 6.41).

Justification for recommendation 13: The Pfeiffer SPMSQ comprises ten questions administered by the healthcare provider to detect cognitive impairment based on mistakes made by the patient, where 0–2 errors is normal, 3–4 errors indicates slight deterioration, 5–7 errors moderate deterioration, and 8–10 errors severe deterioration. The Pfeiffer SPMSQ is easy for clinicians to use and has been validated among diverse samples of elderly subjects in terms of their ethnic origin and health status. The scoring system also takes the patient’s level of education into account.⁴²

Spiritual assessment

Recommendation 14: Use the GES (Grupo Espiritualidad de la SECPAL-Scale developed by the Spirituality Group of the Spanish Palliative Care Society) scale to assess patients’ spiritual resources and needs.⁴³

Degree of consensus: Strongly agree (1st round agreement 5.68; 2nd round agreement 6.06). The question was modified from “use the GES scale to assess patients’ spiritual need” in the 1st round to “receive training on use of the GES scale to assess patients’ spiritual needs” in the 2nd round, following comments by the experts).

Justification for recommendation 14: The GES scale, developed by the Spirituality Group (Spanish acronym: GES) of the Spanish Palliative Care Society, is a questionnaire available in Spanish and English for assessing patients’ spiritual resources and needs on the intrapersonal, interpersonal, and transpersonal levels. It supports clinicians to explore these levels with the patient, to identify needs as well as their existing resources or strengths.⁴⁴

The GES scale has factorial validity, clear evidence of reliability (α = 0.72), and a coherent relationship with other measures of spirituality, depression, anxiety, and resilience.

The Spirituality Group recommends that use of the scale be limited to experienced professionals with knowledge of the GES model and an empathic and trusting relationship with the patient. Candidate patients are those with advanced or terminal illness and an awareness of the possibility of imminent death.^43,45

Sedation assessment

Recommendation 15: Use the Ramsay Scale to assess the patient’s level of consciousness during palliative sedation.⁴⁶

Degree of consensus: Strongly agree (1st round agreement 6.41).

Justification for recommendation 15: In 1974, Ramsay M. developed an awareness level scale, dividing the level of consciousness during sedation into six categories ranging from severe agitation to deep coma.⁴⁶

One objective of such scales is to assess the quality of palliative sedation.⁴⁷ The Ramsay sedation scale sometimes falls short for intensive care unit patients but is nonetheless frequently used in palliative care, alongside other tools such as the Richmond Agitation Sedation Scale.^47,48 A systematic review found no clear evidence on the overall quality or effectiveness of palliative sedation and concluded that work is needed to identify assessment parameters.⁴⁷ Since the Ramsay scale is relatively easy to use and commonplace in palliative care, it achieved a high degree of consensus from our experts.

Prognosis assessment

Recommendation 16: Use the Palliative Prognostic (PaP) Score as a prognostic tool in palliative cancer patients not undergoing cancer treatment.⁴⁹

Degree of consensus: Strongly agree (1st round agreement 6.50).

Justification for recommendation 16: The Pap Score yields the probability of a palliative care patient’s survival at 30 days.⁴⁹ It scores the following variables: dyspnoea, anorexia, Karnofsky index, clinical prediction of survival in weeks, total leukocytes, and % lymphocytes. Patients are then divided into three groups based on their probability of survival at 30 days: group A (<70%), group B (30%–70%), and group C (<30%). The Clinical Practice Guide on Palliative Care of the Spanish Ministry of Health states that an estimation of the survival of advanced cancer patients should take into account the results of prognostic tools such as the Karnofsky Performance Scale Index or the PaP.⁵⁰ These have a grade C recommendation from the American Society of Clinical Oncology.⁵¹ The Pap Score is currently only recommended for use in specialist palliative care or oncology units and has not been validated for use in patients with hematologic malignancies.^52–55

Recommendation 17: Use the Edmonton Classification System for Cancer Pain (ECS-CP) as a prognostic assessment of cancer pain.⁵⁶

Degree of consensus: Strongly agree (1st round agreement 6.68).

Justification for recommendation 17: The ECS-CP in its various forms has long provided a comprehensive overview of the entire cancer pain staging process. Classification of cancer pain requires a multidimensional assessment, and the ECS-CP encompasses dimensions believed useful in achieving stable pain control: mechanism of pain, incidental pain, psychological distress, addictive behavior, and cognitive impairment.⁵⁷ It has the potential for further use in cancer care research, for example, capturing the characteristics of a population to boost comparability between studies. It also facilitates communication between doctors and researchers.⁵⁸

Advanced care planning assessment

Recommendation 18: Routinely include shared decision-making/advanced care planning in the multidimensional palliative care assessment.

Degree of consensus: Strongly agree (1st round agreement 6.00).

Justification for recommendation 18: A recent article by Agarwal and Epstein highlights the importance of advanced care planning “to support the personhood of patients with advanced cancer.” The healthcare team must encourage patients to express “what matters and provides meaning to them as they live, cope, and receive treatment for their cancer.”⁵⁹ Good medical practice does not exist without respect for the will of the patient with the right to participate in their own healthcare planning, and a Spanish law on patient autonomy proclaims that health personnel have a professional, legal, and ethical responsibility to ensure and encourage this form of patient participation.^60,61 Patients’ needs and wishes should therefore be recorded in advanced care planning. This helps uphold their autonomy by providing a means with which to continue exercising it once they are no longer able to communicate their wishes.^60,62

Diagnostic and therapeutic intervention

Recommendation 19: Use the Diagnostic and Therapeutic Intervention Levels for the hospitalized patient to agree on the clinical approach in case of complications. Table 1 presents the ICO Diagnostic and Therapeutic Intervention Levels.

Degree of consensus: Strongly agree (1st round agreement 6.27).

Justification for Recommendation 19: In 2013, the Catalan ICO developed evidence-based, end-of-life care guidelines with the following aims:⁶⁰

Improve the cost-effectiveness of end-of-life care, based on the available scientific evidence.

Reduce the variability of approaches between ICO teams.

Facilitate a comprehensive and multidimensional approach to the end-of-life process in patients with malignant neoplasm.

Establish assessment criteria for end-of-life patients.

Table 1.

The Catalan Institute of Oncology Diagnostic and Therapeutic Intervention Levels

Level 1: Patient eligible for all diagnostic-therapeutic measures

Level 2: Same as 1 except CPR, orotracheal intubation for assisted ventilation or ICU

Level 3: Dependent upon intercurrent events

◦ 3A: Level 2 measures may be used temporarily based on the evolution of the events

◦ 3B: No new measures initiated

◦ 3C: Gradual withdrawal of measures

Level 4: Symptomatic treatment and keeping the patient comfortable

Patients nearing the end of life may receive different diagnoses and be subject to different therapeutic approaches depending on the disease stage, type of complication, or even the treating professional they encounter at any given time. In the Diagnostic and Therapeutic Intervention Levels, the patient’s assigned level is recorded, and all healthcare providers agree on the clinical approach in the event of complications. The patient’s level may vary over the course of their hospitalization.

In palliative care, the concept of limitation of therapeutic effort (LTE) means not taking heroic or disproportionate measures for patients with a poor short-term prognosis or poor quality of life.^60,63,64 Limiting therapeutic effort may involve withholding or withdrawing certain treatments. It may also mean that healthcare teams proactively offer or modify measures based on the current therapeutic goals and the resources available. ICO’s Diagnostic and Therapeutic Intervention Levels, developed in Spanish, help ensure practical application of LTE for patients with malignant neoplasm.⁶⁰ Bioethical principles must be considered when LTE is adopted.

Discussion

The ICO Toolkit-2 is a significant step forward from the original toolkit, with several new recommendations included:

Recommendation 5 on the Braden Scale.

Recommendation 9 on the Emotional Disorder Detection Questionnaire.

Recommendation 11 on the WTHD.

Recommendation 15 on the Ramsay Scale.

Recommendation 18 on shared decision-making/advanced care planning.

Recommendation 19 on the ICO Diagnostic and Therapeutic Intervention Levels.

The instruments in the original toolkit were selected by a working group comprising five doctors, four psycho-oncologists, and four social workers, with no nursing representation. The 24 professionals involved in the Delphi process for the ICO Toolkit-2 included six nurses selected from ICO’s three main centers. This adds a valuable additional dimension to the toolkit, given the involvement of nurses throughout the patient care journey—particularly in palliative care—in supporting families and care partners.

Cancer patients in palliative care have multifaceted needs. These needs, and those of their families and care partners, are likely to change over the course of treatment. Though several instruments exist for conducting a multidimensional assessment, there is little guidance currently on how and when to implement them.

Like its predecessor, the idea behind the ICO Toolkit-2 is to facilitate a systematic palliative care assessment that comprehensively addresses patients’ needs. The toolkit format pools our recommendations in one place, giving healthcare professionals a central point of reference and clear guidelines to aid their decision-making around patient care and follow-up.

Lastly, the toolkit goes beyond the physical dimension, with instruments to assess emotional, cognitive, and spiritual needs. This provides scope for encompassing unique social and cultural factors that may, in turn, determine which recommendations are most appropriate on an individual basis.

Conclusions

The updated ICO Toolkit-2 supports clinicians to conduct a systematic, multidimensional assessment of patients with malignant neoplasm in palliative care. With the toolkit, clinicians can objectively identify and measure the needs of these patients and those of their families and care partners. Furthermore, they can record the results of interventions to aid both clinical practice and research.

Use of the toolkit nationally, and by the wider medical community, may go some way to ensuring consistency of care for patients with malignant neoplasms receiving palliative care. Decisions on whether to apply the toolkit should be made in agreement with all healthcare professionals involved in patient care.

The recommendations should be updated in response to new palliative care instruments and tools that become available.

Footnotes

Acknowledgments

The authors thank Kelsie Pettit DipTrans MCIL for external editing services and English language support. The authors also thank the three Palliative Care Services of the Catalan Institute of Oncology—L’Hospitalet de Llobregat, Badalona, and Girona—for their participation.

Author Disclosure Statement

The authors declare they have no conflicts of interest to disclose.

Funding Information

The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

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