From Inpatient Care to Palliative Care: Socio-demographic Characterization and Waiting Times of Referred Oncology Patients

From Inpatient Care to Palliative Care: Socio-demographic Characterization and Waiting Times of Referred Oncology Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Inpatient Care to Palliative Care: Socio-demographic Characterization and Waiting Times of Referred Oncology Patients Pedro Antunes Meireles, Inês Vicente, Bernardo Pereira, Carolina Pereira, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7530098/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Timely access to specialized palliative care significantly improves quality of life and symptom control for oncology patients. This study aimed to characterize socio-demographic profiles, evaluate waiting times for referral and admission, and identify barriers to efficient integration of patients referred from the inpatient oncology unit to specialized palliative care units. Methods: We conducted a retrospective observational study including all oncology patients admitted to the Medical Oncology inpatient unit at Instituto Português de Oncologia de Lisboa Francisco Gentil from January 2022 to June 2024 who were referred to palliative care units. Data collected included socio-demographic variables, primary tumour types, waiting times from palliative care unit referral to admission or death, length of stay post-admission to a palliative care unit, and involvement of the local hospital palliative care team. Statistical analyses included descriptive statistics, Kaplan-Meier survival analysis, and comparative subgroup analyses. Results: Of 3177 hospitalised oncology patients, 208 (6.5%) were referred to specialized palliative care. Referrals were predominantly females (64.9%) and the median age was 70 years (IQR: 62–77.8). The most common diagnosis were head and neck (21.6%), breast (17.8%), digestive (17.3%), and gynecological (16.3%) cancers. Only 37% of referred patients were admitted to palliative care units, while 63% died before admission. Median waiting time was 29.5 days (IQR: 20.3–40.8) for those admitted and 34 days (IQR: 20–54) for those who died without being admitted. Median length of stay post-admission to a palliative care unit until death was 21.5 days (IQR: 9.8–40.3). No statistically significant differences were observed in waiting times based on age or sex. However, referral-to-outcome intervals varied significantly by tumour type, with shorter delays for patients with skin cancer and longer delays for those with gynecological cancers and sarcomas (p < 0.05). Discussion: Significant delays in accessing specialized palliative care persist, influenced by structural barriers, patient and family decision-making, geographical factors, and limited availability. The interruption of a transitional support protocol, which previously facilitated coordination between hospital discharge and formal admission to palliative care units, contributed to increased waiting times. Such inefficiencies carry substantial clinical and socioeconomic consequences, emphasizing the urgency of addressing these barriers through improved policy, structured protocols, and early intervention strategies. Conclusion: Efficient integration of oncology patients into palliative care units remains challenging. Enhancing referral processes, renewing intermediate care agreements, and promoting patient and family education are crucial to mitigate delays and optimize patient outcomes. Palliative care Referral Oncology Waiting times Socio-demographic factors Key Messages Timely referral to palliative care remains limited, with most patients (63%) dying before admission. Structural barriers, family decision-making delays, and limited bed availability hinder timely referrals. Loss of an intermediate care agreement notably increased admission delays. Early integration and structured referral protocols could significantly improve patient outcomes. Socioeconomic implications underscore the urgent need for policy interventions to streamline referrals. Introduction Cancer remains a major public health concern, being responsible for nearly 10 million deaths worldwide each year and representing the second leading cause of death globally, as well as in Portugal. [ 1 , 2 ] Advances in oncology have significantly improved survival rates; however, many patients still experience advanced disease states characterized by complex symptomatology, reduced quality of life, and significant emotional and physical distress. [ 3 , 4 ] Palliative care is an essential component of comprehensive cancer management, aiming to relieve suffering, enhance quality of life, and provide support to patients and families facing life-threatening illnesses. [ 5 ] Despite robust evidence showing that early integration of palliative care into oncology care pathways leads to improved patient outcomes, including symptom control, quality of life, and even survival, it remains underutilized in clinical practice, with substantial barriers still identified in referral pathways and timely access. [ 6 , 7 ] In Portugal, although significant efforts have been made to expand the national palliative care network, notable gaps persist. According to the July 2024 monitoring report published by the Portuguese Health Regulatory Authority (Entidade Reguladora da Saúde, ERS), substantial waiting times remain a challenge, and a significant proportion of patients referred to specialized palliative care units die before admission. [ 8 ] Such delays are problematic, resulting in suboptimal symptom management, increased distress for patients and families, prolonged hospitalizations, and higher healthcare costs. [ 9 ] Understanding the socio-demographic profile of oncology patients referred for specialized palliative care, as well as quantifying the waiting times between referral and admission or death, is crucial. These data can inform targeted interventions, streamline referral processes, and guide policy decisions aimed at enhancing service delivery and equity of access. The goal of this study was to characterize the cancer patient population referred from the Medical Oncology inpatient Unit of Instituto Português de Oncologia de Lisboa Francisco Gentil (IPOLFG) to palliative care units (PCU). Specifically, we aimed to describe patient socio-demographic characteristics, analyse waiting times from referral to admission to PCU or death, and evaluate hospital length-of-stay post-admission into palliative care. We also assessed the role of our in-hospital palliative care support team in this referral process. Methods Study Design and Setting This was a retrospective observational cohort study conducted at the Medical Oncology inpatient unit of IPOLFG, a comprehensive cancer centre in Lisbon, Portugal. The study complied with STROBE guidelines. Study Population All oncology patients admitted to the Medical Oncology inpatient unit between January 2022 and June 2024 were screened for inclusion. Patients were included if they were referred from inpatient care to specialized palliative care units during this period. Patients without complete data records or who were transferred to other acute-care facilities were excluded. Data Collection Data were collected retrospectively from electronic medical records. The following variables were extracted: Socio-demographic data: age, sex. Clinical data: primary tumour site/type, metastatic status at referral. Hospital admission data: dates of admission and discharge or death, total length of stay. Palliative care referral data: date of referral, date of admission to a palliative care unit/PCU (if admitted), date of death (if occurred before admission to PCU). Follow-up data: total length of stay in the palliative care unit/PCU until death (if applicable). Presence or absence of involvement by the hospital’s specialized intrahospital palliative care support team. Additionally, for both admitted and non-admitted patients, we collected specific time intervals along the referral trajectory: from hospital admission to first evaluation by the intrahospital palliative care team, from evaluation to registration on the national referral platform, and from registration to either admission or death. Outcomes The primary outcomes of interest included: 1. Socio-demographic and clinical characterization of patients referred to palliative care. 2. Median and average waiting times from referral to admission to a palliative care unit or death. 3. Median duration of inpatient stay at the palliative care units until death (if applicable). Statistical Analysis Descriptive statistics were used to summarize demographic and clinical data. Continuous variables were presented as means ± standard deviations (SD) or medians and interquartile ranges (IQR), depending on data distribution. Categorical variables were reported as absolute frequencies and percentages. Kaplan-Meier survival analysis was conducted to estimate the time intervals between referral and admission/death. Comparative analyses of subgroups (by tumour type, sex, and involvement of the hospital's palliative care team) were performed using appropriate tests (Mann-Whitney U test or Chi-square test), considering a significance level of p < 0.05. When multiple pairwise comparisons were conducted, p-values were interpreted in light of Bonferroni correction to account for the risk of type I error. Statistical analyses were performed using SPSS software, version 30.0. Ethical Approval The study protocol was reviewed and approved by the Ethics Committee of IPOLFG (reference number: UIC/1790). Given the retrospective design and anonymized nature of data collection, informed consent was waived. Results Patient Characteristics From January 2022 to June 2024, a total of 3177 oncology patients were hospitalized in our Medical Oncology inpatient unit. Among these, 208 (6.5%) were referred to specialised palliative care units. The median age of referred patients was 70 years (IQR: 62–77.8), with a predominance of females (64.9%; n = 135). The most frequent primary cancers in this subgroup were head and neck (21.6%), breast (17.8%), digestive (17.3%), and gynecological (16.3%) (Table 1). Table 1 Tumor type Frequency Valid Percent Genitourinary N= 13 6.3% Gynecological N= 34 16.3% Breast N= 37 17.8% Lung N= 1 0.5% Skin N= 20 9.6% Head & Neck N= 45 21.6% Digestive N= 36 17.3% Sarcoma N= 15 7.2% Other N= 7 3.4% Total 208 100.0% Legend: Distribution of tumor types among oncology patients referred to palliative care units (PCU) between January 2022 and June 2024. Values are expressed as absolute frequencies and percentages. Referral and Admission to Palliative Care Of the 208 patients referred to palliative care, 77 (37%) were admitted to specialized units, while 131 (63%) died before admission. The median interval between referral to admission was 29.5 days (IQR: 20.3–40.8), whereas the median time from referral to death among those who did not reach admission was 34 days (IQR: 20–54) (Table 2). In addition, a descriptive sub-analysis of key timepoints along the referral process was conducted using mean values. Among admitted patients, the mean time from hospital admission to evaluation by the intrahospital palliative care team was 11.8 days, followed by a mean of 14.1 days until registration on the national referral platform, and a further 28.9 days until admission to a PCU. This resulted in an average total interval of 44.1 days from hospitalisation to palliative care admission. For patients who were not admitted, the mean time from hospitalisation to palliative care team evaluation was shorter (7.8 days), followed by 13.9 days until registration, and 14.7 days from registration to death, with an overall mean time of 34.8 days from hospitalisation to death. Table 2 Variable N Median (IQR) Mean ± SD Age (years) 208 70.0 (62.0–77.8) 68.6 ± 11.9 Length of hospital stay (days) 208 27.5 (18.0–41.0) 33.4 ± 26.4 Hospitalization to death (days) 208 34.0 (20.0–54.0) 44.3 ± 39.2 PCU admission to death (days) 74 21.5 (9.8–40.3) 32.4 ± 34.9 Legend : Descriptive statistics of patient age and time intervals from hospitalization to palliative care or death. Values are presented as medians with interquartile ranges (IQR) and means with standard deviations (SD). PCU: Palliative Care Unit. There was no statistically significant difference in waiting times from hospital referral to admission to palliative care when comparing patients by age groups (0–69 and 70–98 years; p = 0.192) or sex (p = 0.634). Among patients admitted to palliative care units, the time from referral to admission varied across different tumour types, although the difference was not statistically significant (Kruskal-Wallis test, H = 1.690, p = 0.639). On the other hand, a Kruskal-Wallis test indicated a statistically significant difference in referral-to-outcome times across tumour types (H = 14.697, p = 0.023). Pairwise comparisons using Mann-Whitney U test identified several significant differences (Table 3). Patients with skin tumours had significantly shorter intervals from referral to final outcome compared to those with gynecological tumours (p < 0.001) and sarcomas (p = 0.028). Additionally, patients with gynecological tumours had significantly longer intervals than those with breast cancer (p = 0.019). No other comparisons reached statistical significance. A selective approach was applied, focusing only on clinically relevant tumour types with sufficient sample sizes. While the comparison between skin and gynecological tumours remained highly significant even after Bonferroni correction, other p-values (e.g., sarcoma vs. skin and gynecological vs. breast) were interpreted cautiously due to their proximity to the correction threshold (adjusted significance level ≈ 0.008). Nevertheless, these findings may reflect underlying biological and clinical differences in disease trajectories, prognosis, or referral practices. Table 3 : Tumor Type N Median (IQR), days Significant Pairwise Differences (Mann-Whitney U) Skin 20 20 (14) vs. Gynecological (p < 0.001); vs. Sarcoma (p = 0.028) Gynecological 34 34.5 (24) vs. Skin (p < 0.001); vs. Breast (p = 0.019) Breast 37 26 (30) vs. Gynecological (p = 0.019) Digestive 36 28 (31) – Head and Neck 45 28 (23) – Sarcoma 15 36 (40) vs. Skin (p = 0.028) Others 21 27 (20) – Legend : Values expressed as median and interquartile range (IQR). Pairwise comparisons performed using Mann-Whitney U test. Statistically significant results (p < 0.05) are shown. Comparisons were selectively conducted between tumour groups with meaningful clinical and statistical differences. Bonferroni correction was considered in interpretation. Length of Stay and Mortality in Palliative Care Units Among patients admitted to palliative care units, the median length of stay until death was 21.5 days (IQR: 9.8–40.3). By the end of the study period, 74 of the 77 admitted patients (96.1%) had died during their stay in the palliative care units (Table 4). Table 4 Variable N Median (IQR), days Mean ± SD, days Min–Max Length of hospital stay 208 27.5 (18.0–41.0) 33.4 ± 26.4 4–219 Hospitalization to death 208 34.0 (20.0–54.0) 44.3 ± 39.2 4–238 Hospitalization to PCU admission 77 29.5 (20.3–40.8) 44.1 ± 28.9 — PCU admission to death 74 21.5 (9.8–40.3) 32.4 ± 34.9 1–149 Legend: Time intervals along the patient care trajectory from hospitalization to referral and palliative care outcomes. Values are expressed as medians with interquartile ranges (IQR), means with standard deviations (SD), and ranges (Min–Max). PCU: Palliative Care Unit. Role of the Hospital Support Palliative Care Team All referred patients were previously assessed in coordination with the hospital support palliative care team. While this multidisciplinary involvement did not have a statistically significant impact on referral success or duration, it remains essential in guiding the evaluation process, ensuring appropriate clinical judgement, and facilitating communication with patients and families. Discussion This study analysed the socio-demographic profile and waiting times of oncology patients referred from our inpatient medical oncology unit to specialised PCU. Despite advances in the integration of palliative care into oncology management, significant challenges and barriers to timely referral and admission remain evident. Our findings demonstrate that a considerable proportion of patients (63%) referred to PCU died before being admitted, with a median waiting time of approximately one month from referral to either admission or death. Such delays highlight the ongoing gaps in capacity and organisation within the national palliative care network, consistent with recent national reports. [8] A more detailed analysis of the referral pathway provided valuable insight into the complexity and duration of the process. Among patients who were ultimately admitted to a PCU, the mean time from hospital admission to the first evaluation by the intrahospital palliative care team was 11.8 days. This was followed by an average of 14.1 days until formal registration on the national referral platform, and a further 28.9 days until PCU admission, resulting in a cumulative mean delay of 44.1 days from hospitalisation to transfer. In contrast, patients who were referred but died before admission had a mean of 7.8 days to first evaluation, 13.9 days until registration, and 14.7 days from registration to death, amounting to a total of 34.8 days. These data suggest that delays are multifactorial, involving not only institutional or logistical barriers, but also delays in clinical decision-making and administrative processing. Several factors were identified that contributed substantially to delays or prevented referral. Patients originating from Portuguese-speaking African countries (PALOP), who lacked formal agreements or protocols for admission to palliative care units, represented a significant challenge. The absence of structured referral pathways created substantial logistical barriers, delaying effective care. Moreover, family-related delays were frequent, reflecting complex decision-making processes involving end-of-life care choices. Patient refusal to accept referral to PCU, often due to misconceptions, cultural factors influencing perceptions of palliative care, or geographical limitations, such as distance from the PCU or families, also significantly contributed to delayed or unfulfilled referrals. Furthermore, the limited capacity and prolonged waiting times in palliative care institutions further exacerbated the issue. Additionally, several patients were referred too late in the disease trajectory, having insufficient clinical stability or life expectancy for successful transition to specialised units. This issue emphasises the importance of early integration of palliative care discussions and decision-making processes into routine oncology practice. The termination, in 2022, of a previously existing collaboration with an intermediate care facility further worsened referral and admission delays. This intermediate care unit previously facilitated smoother transitions, and its closure likely contributed to increased pressure on existing palliative care resources. Important limitations must also be recognised. First, our retrospective design precluded precise tracking of specific times when consent forms were signed versus when referrals were effectively initiated. Thus, the measured waiting times may not fully reflect the complexity of the referral process. Additionally, due to the lack of clinical follow-up records from external PCU, clinical outcomes and complications occurring post-admission to PCU were likely underreported. Although awareness regarding the importance of palliative care is increasing in Portugal, similar studies remain scarce in the national context, hindering direct comparisons. Nevertheless, recent national data from ERS indicate significant regional disparities and inadequacies in the availability of specialised palliative care beds in Portugal, with only about 72% of the population having access to a PCU within 60 minutes' travel time. Furthermore, almost half (48%) of patients referred to palliative care units died before admission, highlighting systemic inefficiencies with profound socioeconomic impacts. These include increased healthcare costs related to prolonged stays in acute care hospitals, caregiver burden, and reduced overall healthcare system efficiency due to inappropriate utilisation of acute-care beds. [8] Beyond evident clinical impacts, these delays carry significant socioeconomic consequences, including unnecessarily prolonged hospitalisations, increased burden on families and informal caregivers, and substantial costs associated with keeping patients in acute hospital units, which are typically more expensive when compared to specialised palliative care facilities. International estimates suggest that early and effective integration of palliative care can significantly reduce healthcare costs, simultaneously benefiting patients, families, and healthcare systems. Given the Portuguese context, optimising referral processes may thus yield considerable gains in economic and social sustainability, warranting particular attention from policy makers and clinical managers. Conclusion Our study highlights persistent gaps in the referral process and timely admission of oncology patients to specialized palliative care units. It underscores the importance of addressing structural, procedural, and socio-cultural barriers to improve timely palliative care integration. Renewed agreements with intermediate facilities, patient and family education, and streamlined referral protocols are essential to reduce delays and enhance both patient care and health system sustainability. Detailed tracking of each stage in the referral pathway also provides concrete targets for procedural improvements, allowing institutions to identify and act upon avoidable administrative and clinical delays. Further studies are needed to assess the long-term impact of implemented interventions and to explore patient and caregiver experiences to ensure alignment of services with patient needs and preferences. Statements & Declarations Funding This study received no specific public or private funding. The authors declare no conflicts of interest. This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethical Considerations This study was conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by the Ethics Committee of Instituto Português de Oncologia de Lisboa (reference number UIC/1790). Data confidentiality was strictly maintained, and patient informed consent was waived due to the retrospective and observational nature of the study, with full anonymization of data. Previous Awards and Presentations None to declare. Competing Interests The authors declare that they have no competing interests, financial or non-financial. Author Contributions Pedro Antunes Meireles: study conception and design, data collection, statistical analysis, manuscript drafting. Inês Vicente, Bernardo Pereira, Carolina Pereira, Sara Magno: data collection Inês Vicente, Bernardo Pereira, Carolina Pereira, Sara Magno, Carolina Coelho, Madalena Feio, Cláudia Romão, Fátima Vaz: critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript. Ethics Approval This study was approved by the Ethics Committee of Instituto Português de Oncologia de Lisboa (reference number: UIC/1790). Consent to Participate Patient informed consent was waived due to the retrospective and anonymized nature of the study, in accordance with institutional and national regulations. Consent for Publication Not applicable, as no individual patient data or images are presented that would require consent for publication. Data Availability The datasets generated and/or analysed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request. References Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209-49. doi:10.3322/caac.21660 Direção-Geral da Saúde. Portugal – Doenças Oncológicas em Números – 2021. Lisboa: DGS; 2021. Hui D, Hannon BL, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. CA Cancer J Clin. 2018;68(5):356-76. doi:10.3322/caac.21490 Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-42. doi:10.1056/NEJMoa1000678 World Health Organization. Palliative care [Internet]. Geneva: WHO; 2020 [cited 2024 May 15]. Available from: https://www.who.int/news-room/fact-sheets/detail/palliative-care Kaasa S, Loge JH, Aapro M, Albreht T, Anderson R, Bruera E, et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol. 2018;19(11):e588-653. doi:10.1016/S1470-2045(18)30415-7 Jordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Martin A, Currow DC, et al. Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. BMC Med. 2020;18(1):368. doi:10.1186/s12916-020-01829-x Entidade Reguladora da Saúde. Informação de Monitorização: Avaliação do acesso a Cuidados Paliativos em Portugal Continental. Lisboa: ERS; 2024 Jul [cited 2024 Aug 20]. Available from: https://www.ers.pt/media/ee2ge4yv/im_rncp_08-22024.pdf Silva MD, Gomes B, Antunes B, Ferreira PL, Sarmento VP, Pinto C. Portuguese national programme for palliative care: Overview and challenges ahead. Int J Palliat Nurs. 2022;28(4):184-91. doi:10.12968/ijpn.2022.28.4.184 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7530098","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511245133,"identity":"1ca55564-365c-4377-938e-3cea88aac1c7","order_by":0,"name":"Pedro Antunes 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referral protocols could significantly improve patient outcomes.\u003c/li\u003e\n \u003cli\u003eSocioeconomic implications underscore the urgent need for policy interventions to streamline referrals.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eCancer remains a major public health concern, being responsible for nearly 10\u0026nbsp;million deaths worldwide each year and representing the second leading cause of death globally, as well as in Portugal. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Advances in oncology have significantly improved survival rates; however, many patients still experience advanced disease states characterized by complex symptomatology, reduced quality of life, and significant emotional and physical distress. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003ePalliative care is an essential component of comprehensive cancer management, aiming to relieve suffering, enhance quality of life, and provide support to patients and families facing life-threatening illnesses. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Despite robust evidence showing that early integration of palliative care into oncology care pathways leads to improved patient outcomes, including symptom control, quality of life, and even survival, it remains underutilized in clinical practice, with substantial barriers still identified in referral pathways and timely access. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn Portugal, although significant efforts have been made to expand the national palliative care network, notable gaps persist. According to the July 2024 monitoring report published by the Portuguese Health Regulatory Authority (Entidade Reguladora da Sa\u0026uacute;de, ERS), substantial waiting times remain a challenge, and a significant proportion of patients referred to specialized palliative care units die before admission. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Such delays are problematic, resulting in suboptimal symptom management, increased distress for patients and families, prolonged hospitalizations, and higher healthcare costs. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eUnderstanding the socio-demographic profile of oncology patients referred for specialized palliative care, as well as quantifying the waiting times between referral and admission or death, is crucial. These data can inform targeted interventions, streamline referral processes, and guide policy decisions aimed at enhancing service delivery and equity of access.\u003c/p\u003e\u003cp\u003e The goal of this study was to characterize the cancer patient population referred from the Medical Oncology inpatient Unit of Instituto Portugu\u0026ecirc;s de Oncologia de Lisboa Francisco Gentil (IPOLFG) to palliative care units (PCU). Specifically, we aimed to describe patient socio-demographic characteristics, analyse waiting times from referral to admission to PCU or death, and evaluate hospital length-of-stay post-admission into palliative care. We also assessed the role of our in-hospital palliative care support team in this referral process.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\n \u003cp\u003eThis was a retrospective observational cohort study conducted at the Medical Oncology inpatient unit of IPOLFG, a comprehensive cancer centre in Lisbon, Portugal. The study complied with STROBE guidelines.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eAll oncology patients admitted to the Medical Oncology inpatient unit between January 2022 and June 2024 were screened for inclusion. Patients were included if they were referred from inpatient care to specialized palliative care units during this period. Patients without complete data records or who were transferred to other acute-care facilities were excluded.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected retrospectively from electronic medical records. The following variables were extracted:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eSocio-demographic data: age, sex.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eClinical data: primary tumour site/type, metastatic status at referral.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHospital admission data: dates of admission and discharge or death, total length of stay.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePalliative care referral data: date of referral, date of admission to a palliative care unit/PCU (if admitted), date of death (if occurred before admission to PCU).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eFollow-up data: total length of stay in the palliative care unit/PCU until death (if applicable).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePresence or absence of involvement by the hospital\u0026rsquo;s specialized intrahospital palliative care support team.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAdditionally, for both admitted and non-admitted patients, we collected specific time intervals along the referral trajectory: from hospital admission to first evaluation by the intrahospital palliative care team, from evaluation to registration on the national referral platform, and from registration to either admission or death.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes of interest included:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e1. Socio-demographic and clinical characterization of patients referred to palliative care.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e2. Median and average waiting times from referral to admission to a palliative care unit or death.\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e3. Median duration of inpatient stay at the palliative care units until death (if applicable).\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eDescriptive statistics were used to summarize demographic and clinical data. Continuous variables were presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD) or medians and interquartile ranges (IQR), depending on data distribution. Categorical variables were reported as absolute frequencies and percentages. Kaplan-Meier survival analysis was conducted to estimate the time intervals between referral and admission/death. Comparative analyses of subgroups (by tumour type, sex, and involvement of the hospital\u0026apos;s palliative care team) were performed using appropriate tests (Mann-Whitney U test or Chi-square test), considering a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. When multiple pairwise comparisons were conducted, p-values were interpreted in light of Bonferroni correction to account for the risk of type I error. Statistical analyses were performed using SPSS software, version 30.0.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe study protocol was reviewed and approved by the Ethics Committee of IPOLFG (reference number: UIC/1790). Given the retrospective design and anonymized nature of data collection, informed consent was waived.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom January 2022 to June 2024, a total of\u0026nbsp;3177 oncology patients were hospitalized in our Medical Oncology inpatient unit. Among these, 208 (6.5%) were referred to specialised palliative care units. The median age of referred patients was 70 years (IQR: 62\u0026ndash;77.8), with a predominance of females (64.9%; n = 135). The most frequent primary\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;cancers in this subgroup were head and neck (21.6%), breast (17.8%), digestive (17.3%), and gynecological (16.3%) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValid Percent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eGenitourinary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e6.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eGynecological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e16.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e17.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eSkin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e9.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eHead \u0026amp; Neck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e21.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eDigestive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e17.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eSarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e7.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eN= 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Distribution of tumor types among oncology patients referred to palliative care units (PCU) between January 2022 and June 2024. Values are expressed as absolute frequencies and percentages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral and Admission to Palliative Care\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the 208 patients referred to palliative care, 77 (37%) were admitted to specialized units, while 131 (63%) died before admission. The median interval between referral to admission was 29.5 days (IQR: 20.3\u0026ndash;40.8), whereas the median time from referral to death among those who did not reach admission was 34 days (IQR: 20\u0026ndash;54) (Table 2).\u003c/p\u003e\n\u003cp\u003eIn addition, a descriptive sub-analysis of key timepoints along the referral process was conducted using mean values. Among admitted patients, the mean time from hospital admission to evaluation by the intrahospital palliative care team was 11.8 days, followed by a mean of 14.1 days until registration on the national referral platform, and a further 28.9 days until admission to a PCU. This resulted in an average total interval of 44.1 days from hospitalisation to palliative care admission.\u003c/p\u003e\n\u003cp\u003eFor patients who were not admitted, the mean time from hospitalisation to palliative care team evaluation was shorter (7.8 days), followed by 13.9 days until registration, and 14.7 days from registration to death, with an overall mean time of 34.8 days from hospitalisation to death.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e70.0 (62.0\u0026ndash;77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e68.6 \u0026plusmn; 11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eLength of hospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e27.5 (18.0\u0026ndash;41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e33.4 \u0026plusmn; 26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eHospitalization to death (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e34.0 (20.0\u0026ndash;54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e44.3 \u0026plusmn; 39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003ePCU admission to death (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e21.5 (9.8\u0026ndash;40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 141px;\"\u003e\n \u003cp\u003e32.4 \u0026plusmn; 34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: Descriptive statistics of patient age and time intervals from hospitalization to palliative care or death. Values are presented as medians with interquartile ranges (IQR) and means with standard deviations (SD). PCU: Palliative Care Unit.\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference in waiting times from hospital referral to admission to palliative care when comparing patients by age groups (0\u0026ndash;69 and 70\u0026ndash;98 years; p = 0.192) or sex (p = 0.634).\u003c/p\u003e\n\u003cp\u003eAmong patients admitted to palliative care units, the time from referral to admission varied across different tumour types, although the difference was not statistically significant (Kruskal-Wallis test, H = 1.690, p = 0.639).\u003c/p\u003e\n\u003cp\u003eOn the other hand, a Kruskal-Wallis test indicated a statistically significant difference in referral-to-outcome times across tumour types (H = 14.697, p = 0.023). Pairwise comparisons using Mann-Whitney U test identified several significant differences (Table 3). Patients with skin tumours had significantly shorter intervals from referral to final outcome compared to those with gynecological tumours (p \u0026lt; 0.001) and sarcomas (p = 0.028). Additionally, patients with gynecological tumours had significantly longer intervals than those with breast cancer (p = 0.019). No other comparisons reached statistical significance.\u003c/p\u003e\n\u003cp\u003eA selective approach was applied, focusing only on clinically relevant tumour types with sufficient sample sizes. While the comparison between skin and gynecological tumours remained highly significant even after Bonferroni correction, other p-values (e.g., sarcoma vs. skin and gynecological vs. breast) were interpreted cautiously due to their proximity to the correction threshold (adjusted significance level \u0026asymp; 0.008). Nevertheless, these findings may reflect underlying biological and clinical differences in disease trajectories, prognosis, or referral practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"562\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR), days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificant Pairwise Differences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Mann-Whitney U)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eSkin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e20 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003evs. Gynecological (p \u0026lt; 0.001);\u0026nbsp;\u003c/p\u003e\n \u003cp\u003evs. Sarcoma (p = 0.028)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eGynecological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e34.5 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003evs. Skin (p \u0026lt; 0.001);\u0026nbsp;\u003c/p\u003e\n \u003cp\u003evs. Breast (p = 0.019)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e26 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003evs. Gynecological (p = 0.019)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eDigestive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e28 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eHead and Neck\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e28 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eSarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e36 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003evs. Skin (p = 0.028)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e27 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e: Values expressed as median and interquartile range (IQR). Pairwise comparisons performed using Mann-Whitney U test. Statistically significant results (p \u0026lt; 0.05) are shown. Comparisons were selectively conducted between tumour groups with meaningful clinical and statistical differences. Bonferroni correction was considered in interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLength of Stay and Mortality in Palliative Care Units\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong patients admitted to palliative care units, the median length of stay until death was 21.5 days (IQR: 9.8\u0026ndash;40.3). By the end of the study period, 74 of the 77 admitted patients (96.1%) had died during their stay in the palliative care units (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR), days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD, days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u0026ndash;Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eLength of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e27.5 (18.0\u0026ndash;41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e33.4 \u0026plusmn; 26.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4\u0026ndash;219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eHospitalization to death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e34.0 (20.0\u0026ndash;54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e44.3 \u0026plusmn; 39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4\u0026ndash;238\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eHospitalization to PCU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e29.5 (20.3\u0026ndash;40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e44.1 \u0026plusmn; 28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003ePCU admission to death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e21.5 (9.8\u0026ndash;40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e32.4 \u0026plusmn; 34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1\u0026ndash;149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e Time intervals along the patient care trajectory from hospitalization to referral and palliative care outcomes. Values are expressed as medians with interquartile ranges (IQR), means with standard deviations (SD), and ranges (Min\u0026ndash;Max). PCU: Palliative Care Unit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRole of the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHospital Support Palliative Care Team\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll referred patients were previously assessed in coordination with the hospital support palliative care team. While this multidisciplinary involvement did not have a statistically significant impact on referral success or duration, it remains essential in guiding the evaluation process, ensuring appropriate clinical judgement, and facilitating communication with patients and families.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study analysed the socio-demographic profile and waiting times of oncology patients referred from our inpatient medical oncology unit to specialised PCU. Despite advances in the integration of palliative care into oncology management, significant challenges and barriers to timely referral and admission remain evident.\u003c/p\u003e\n\u003cp\u003eOur findings demonstrate that a considerable proportion of patients (63%) referred to PCU died before being admitted, with a median waiting time of approximately one month from referral to either admission or death. Such delays highlight the ongoing gaps in capacity and organisation within the national palliative care network, consistent with recent national reports. [8]\u003c/p\u003e\n\u003cp\u003eA more detailed analysis of the referral pathway provided valuable insight into the complexity and duration of the process. Among patients who were ultimately admitted to a PCU, the mean time from hospital admission to the first evaluation by the intrahospital palliative care team was 11.8 days. This was followed by an average of 14.1 days until formal registration on the national referral platform, and a further 28.9 days until PCU admission, resulting in a cumulative mean delay of 44.1 days from hospitalisation to transfer. In contrast, patients who were referred but died before admission had a mean of 7.8 days to first evaluation, 13.9 days until registration, and 14.7 days from registration to death, amounting to a total of 34.8 days. These data suggest that delays are multifactorial, involving not only institutional or logistical barriers, but also delays in clinical decision-making and administrative processing.\u003c/p\u003e\n\u003cp\u003eSeveral factors were identified that contributed substantially to delays or prevented referral. Patients originating from Portuguese-speaking African countries (PALOP), who lacked formal agreements or protocols for admission to palliative care units, represented a significant challenge. The absence of structured referral pathways created substantial logistical barriers, delaying effective care. Moreover, family-related delays were frequent, reflecting complex decision-making processes involving end-of-life care choices. Patient refusal to accept referral to PCU, often due to misconceptions, cultural factors influencing perceptions of palliative care, or geographical limitations, such as distance from the PCU or families, also significantly contributed to delayed or unfulfilled referrals. Furthermore, the limited capacity and prolonged waiting times in palliative care institutions further exacerbated the issue. Additionally, several patients were referred too late in the disease trajectory, having insufficient clinical stability or life expectancy for successful transition to specialised units. This issue emphasises the importance of early integration of palliative care discussions and decision-making processes into routine oncology practice.\u003c/p\u003e\n\u003cp\u003eThe termination, in 2022, of a previously existing collaboration with an intermediate care facility further worsened referral and admission delays. This intermediate care unit previously facilitated smoother transitions, and its closure likely contributed to increased pressure on existing palliative care resources.\u003c/p\u003e\n\u003cp\u003eImportant limitations must also be recognised. First, our retrospective design precluded precise tracking of specific times when consent forms were signed versus when referrals were effectively initiated. Thus, the measured waiting times may not fully reflect the complexity of the referral process. Additionally, due to the lack of clinical follow-up records from external PCU, clinical outcomes and complications occurring post-admission to PCU were likely underreported.\u003c/p\u003e\n\u003cp\u003eAlthough awareness regarding the importance of palliative care is increasing in Portugal, similar studies remain scarce in the national context, hindering direct comparisons. Nevertheless, recent national data from ERS indicate significant regional disparities and inadequacies in the availability of specialised palliative care beds in Portugal, with only about 72% of the population having access to a PCU within 60 minutes\u0026apos; travel time. Furthermore, almost half (48%) of patients referred to palliative care units died before admission, highlighting systemic inefficiencies with profound socioeconomic impacts. These include increased healthcare costs related to prolonged stays in acute care hospitals, caregiver burden, and reduced overall healthcare system efficiency due to inappropriate utilisation of acute-care beds. [8]\u003c/p\u003e\n\u003cp\u003eBeyond evident clinical impacts, these delays carry significant socioeconomic consequences, including unnecessarily prolonged hospitalisations, increased burden on families and informal caregivers, and substantial costs associated with keeping patients in acute hospital units, which are typically more expensive when compared to specialised palliative care facilities. International estimates suggest that early and effective integration of palliative care can significantly reduce healthcare costs, simultaneously benefiting patients, families, and healthcare systems. Given the Portuguese context, optimising referral processes may thus yield considerable gains in economic and social sustainability, warranting particular attention from policy makers and clinical managers.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study highlights persistent gaps in the referral process and timely admission of oncology patients to specialized palliative care units. It underscores the importance of addressing structural, procedural, and socio-cultural barriers to improve timely palliative care integration. Renewed agreements with intermediate facilities, patient and family education, and streamlined referral protocols are essential to reduce delays and enhance both patient care and health system sustainability.\u0026nbsp;Detailed tracking of each stage in the referral pathway also provides concrete targets for procedural improvements, allowing institutions to identify and act upon avoidable administrative and clinical delays.\u0026nbsp;Further studies are needed to assess the long-term impact of implemented interventions and to explore patient and caregiver experiences to ensure alignment of services with patient needs and preferences.\u003c/p\u003e"},{"header":"Statements \u0026 Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no specific public or private funding. The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eThis study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by the Ethics Committee of Instituto Portugu\u0026ecirc;s de Oncologia de Lisboa (reference number UIC/1790). Data confidentiality was strictly maintained, and patient informed consent was waived due to the retrospective and observational nature of the study, with full anonymization of data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious Awards and Presentations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests, financial or non-financial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Pedro Antunes Meireles: study conception and design, data collection, statistical analysis, manuscript drafting.\u003c/p\u003e\n\u003cp\u003eIn\u0026ecirc;s Vicente, Bernardo Pereira, Carolina Pereira, Sara Magno: data collection\u003cbr\u003e\u0026nbsp;In\u0026ecirc;s Vicente, Bernardo Pereira, Carolina Pereira, Sara Magno, Carolina Coelho, Madalena Feio, Cl\u0026aacute;udia Rom\u0026atilde;o, F\u0026aacute;tima Vaz: critical revision of the manuscript for important intellectual content.\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was approved by the Ethics Committee of Instituto Portugu\u0026ecirc;s de Oncologia de Lisboa (reference number: UIC/1790).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Patient informed consent was waived due to the retrospective and anonymized nature of the study, in accordance with institutional and national regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable, as no individual patient data or images are presented that would require consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and/or analysed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, \u003cem\u003eet al.\u003c/em\u003e Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. \u003cem\u003eCA Cancer J Clin.\u003c/em\u003e 2021;71(3):209-49. doi:10.3322/caac.21660\u003c/li\u003e\n\u003cli\u003eDire\u0026ccedil;\u0026atilde;o-Geral da Sa\u0026uacute;de. \u003cem\u003ePortugal \u0026ndash; Doen\u0026ccedil;as Oncol\u0026oacute;gicas em N\u0026uacute;meros \u0026ndash; 2021.\u003c/em\u003e Lisboa: DGS; 2021.\u003c/li\u003e\n\u003cli\u003eHui D, Hannon BL, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. \u003cem\u003eCA Cancer J Clin.\u003c/em\u003e 2018;68(5):356-76. doi:10.3322/caac.21490\u003c/li\u003e\n\u003cli\u003eTemel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, \u003cem\u003eet al.\u003c/em\u003e Early palliative care for patients with metastatic non-small-cell lung cancer. \u003cem\u003eN Engl J Med.\u003c/em\u003e 2010;363(8):733-42. doi:10.1056/NEJMoa1000678\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. \u003cem\u003ePalliative care\u003c/em\u003e [Internet]. Geneva: WHO; 2020 [cited 2024 May 15]. Available from: https://www.who.int/news-room/fact-sheets/detail/palliative-care\u003c/li\u003e\n\u003cli\u003eKaasa S, Loge JH, Aapro M, Albreht T, Anderson R, Bruera E, \u003cem\u003eet al.\u003c/em\u003e Integration of oncology and palliative care: a Lancet Oncology Commission. \u003cem\u003eLancet Oncol.\u003c/em\u003e 2018;19(11):e588-653. doi:10.1016/S1470-2045(18)30415-7\u003c/li\u003e\n\u003cli\u003eJordan RI, Allsop MJ, ElMokhallalati Y, Jackson CE, Martin A, Currow DC, \u003cem\u003eet al.\u003c/em\u003e Duration of palliative care before death in international routine practice: a systematic review and meta-analysis. \u003cem\u003eBMC Med.\u003c/em\u003e 2020;18(1):368. doi:10.1186/s12916-020-01829-x\u003c/li\u003e\n\u003cli\u003eEntidade Reguladora da Sa\u0026uacute;de. \u003cem\u003eInforma\u0026ccedil;\u0026atilde;o de Monitoriza\u0026ccedil;\u0026atilde;o: Avalia\u0026ccedil;\u0026atilde;o do acesso a Cuidados Paliativos em Portugal Continental.\u003c/em\u003e Lisboa: ERS; 2024 Jul [cited 2024 Aug 20]. Available from: https://www.ers.pt/media/ee2ge4yv/im_rncp_08-22024.pdf\u003c/li\u003e\n\u003cli\u003eSilva MD, Gomes B, Antunes B, Ferreira PL, Sarmento VP, Pinto C. Portuguese national programme for palliative care: Overview and challenges ahead. \u003cem\u003eInt J Palliat Nurs.\u003c/em\u003e 2022;28(4):184-91. doi:10.12968/ijpn.2022.28.4.184\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palliative care, Referral, Oncology, Waiting times, Socio-demographic factors","lastPublishedDoi":"10.21203/rs.3.rs-7530098/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7530098/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTimely access to specialized palliative care significantly improves quality of life and symptom control for oncology patients. This study aimed to characterize socio-demographic profiles, evaluate waiting times for referral and admission, and identify barriers to efficient integration of patients referred from the inpatient oncology unit to specialized palliative care units.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003e We conducted a retrospective observational study including all oncology patients admitted to the Medical Oncology inpatient unit at Instituto Portugu\u0026ecirc;s de Oncologia de Lisboa Francisco Gentil from January 2022 to June 2024 who were referred to palliative care units. Data collected included socio-demographic variables, primary tumour types, waiting times from palliative care unit referral to admission or death, length of stay post-admission to a palliative care unit, and involvement of the local hospital palliative care team. Statistical analyses included descriptive statistics, Kaplan-Meier survival analysis, and comparative subgroup analyses.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOf 3177 hospitalised oncology patients, 208 (6.5%) were referred to specialized palliative care. Referrals were predominantly females (64.9%) and the median age was 70 years (IQR: 62\u0026ndash;77.8). The most common diagnosis were head and neck (21.6%), breast (17.8%), digestive (17.3%), and gynecological (16.3%) cancers. Only 37% of referred patients were admitted to palliative care units, while 63% died before admission. Median waiting time was 29.5 days (IQR: 20.3\u0026ndash;40.8) for those admitted and 34 days (IQR: 20\u0026ndash;54) for those who died without being admitted. Median length of stay post-admission to a palliative care unit until death was 21.5 days (IQR: 9.8\u0026ndash;40.3). No statistically significant differences were observed in waiting times based on age or sex. However, referral-to-outcome intervals varied significantly by tumour type, with shorter delays for patients with skin cancer and longer delays for those with gynecological cancers and sarcomas (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cb\u003eDiscussion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSignificant delays in accessing specialized palliative care persist, influenced by structural barriers, patient and family decision-making, geographical factors, and limited availability. The interruption of a transitional support protocol, which previously facilitated coordination between hospital discharge and formal admission to palliative care units, contributed to increased waiting times. Such inefficiencies carry substantial clinical and socioeconomic consequences, emphasizing the urgency of addressing these barriers through improved policy, structured protocols, and early intervention strategies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEfficient integration of oncology patients into palliative care units remains challenging. Enhancing referral processes, renewing intermediate care agreements, and promoting patient and family education are crucial to mitigate delays and optimize patient outcomes.\u003c/p\u003e","manuscriptTitle":"From Inpatient Care to Palliative Care: Socio-demographic Characterization and Waiting Times of Referred Oncology Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-10 07:12:29","doi":"10.21203/rs.3.rs-7530098/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4891f783-2636-4415-a778-7f761ff20dc7","owner":[],"postedDate":"September 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T07:22:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-10 07:12:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7530098","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7530098","identity":"rs-7530098","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}