Advanced respiratory diseases, particularly chronic obstructive pulmonary disease (COPD) and diffuse interstitial lung diseases (ILDs), represent a growing challenge for contemporary healthcare systems. Over recent decades, their prevalence has increased steadily, driven by population ageing and the persistence of harmful environmental exposures. In Spain, the prevalence of COPD in adults aged over 40 years reaches 11.8%, a figure comparable to that reported in other European countries [1,2]. In the case of ILDs, although recent data remain limited, a recent review showed that the global incidence of idiopathic pulmonary fibrosis (IPF) is 5.8 per 100,000 persons (95% CI: 4.8–6.8), with relevant regional variations: 4.4 in Asia, 5.1 in Europe, and 9.0 in North America. Similarly, the estimated global prevalence was 17.7 per 100,000 population (95% CI: 14.0–21.5), being 14.8 in Asia, 14.6 in Europe, and 27.2 in North America [3].

The clinical management of these diseases entails a substantial healthcare and economic burden, owing to recurrent hospitalizations, frequent emergency department visits, and the intensive use of diagnostic and therapeutic resources. In this context, integrated care models have been shown to reduce healthcare costs by improving coordination across levels of care and decreasing readmission rates in this particularly vulnerable population [4]. Likewise, the implementation of structured follow-up strategies and timely referral protocols promotes more efficient and sustainable care.

The hallmark symptoms of advanced respiratory diseases—primarily dyspnoea, fatigue, and pain—have a significant impact on quality of life, limiting patients’ functional capacity, autonomy, and emotional well-being. Effective management requires the combination of pharmacological and non-pharmacological interventions within a model of continuous, patient-centred clinical communication that facilitates dynamic adaptation of treatment to patients’ changing needs [5,6].

The impact of these conditions also extends to informal caregivers, who frequently experience high levels of physical, emotional, and economic burden. Available evidence supports the need to incorporate formal support strategies, including health education, psychological interventions, and social assistance, aimed at enhancing caregiver resilience and fostering a safe and sustainable caregiving environment [7,8].

Moreover, the increasing use of complex technologies such as non-invasive mechanical ventilation (NIMV), high-flow nasal cannula (HFNC) therapy, or lung transplantation raises questions regarding their impact on prognosis and quality of life. Despite their potential benefits, it is essential to integrate these interventions with strategies focused on symptom relief and psychosocial support. Recent literature highlights that a holistic, individualized, and patient-centred approach improves clinical outcomes, reduces suffering, and preserves dignity in advanced stages of disease [9,10].

Taken together, these elements underscore the need for care strategies that combine interventions aimed at prolonging survival with those focused on improving comfort, quality of life, and overall patient well-being, including early assessment by specialized palliative care teams [11].

With regard to COPD, the definition of advanced disease has historically been heterogeneous. Philip et al. [12] proposed criteria based on a forced expiratory volume in one second (FEV1)<30%, severe dyspnoea, impaired quality of life (CAT), or frequent use of healthcare resources; however, their isolated application may lead to misclassification, as symptoms such as dyspnoea, functional limitation, or hospital admissions may be influenced by comorbidities or other factors not directly attributable to COPD. Other proposals have incorporated severe functional limitation, advanced age, multimorbidity, and systemic complications as key elements in identifying the terminal phase [13,14].

A recent national consensus [15] has established more operational criteria. In that document, advanced COPD was defined as the presence of at least severe chronic airflow obstruction (FEV1<50%) together with two or more of the following elements: (1) chronic respiratory failure; (2) dyspnoea assessed by an mMRC grade of 3–4; and (3) significant limitation in basic activities of daily living. Exacerbations and comorbidities were not included due to their variability and the complexity of attribution, nor were tests such as the 6-minute walk test (6MWT) or diffusing capacity of the lung for carbon monoxide (DLCO), for reasons of clinical applicability. These criteria allow a practical and consistent characterization across levels of care and enable identification of a group of patients with reduced short- to medium-term survival [16].

On this basis, two transitions towards palliative care (PC) can be distinguished. The first occurs when advanced disease is present with unmet needs despite optimized treatment [17]. The second corresponds to a situation of terminal illness, when disease progression is irreversible and the focus of care should be directed primarily towards symptom control, emotional support, and preservation of patient dignity (Table 1).

To facilitate early identification of these patients, multiple prognostic variables have been evaluated, including FEV1<30%, reduced physical activity, walking limitation, severe dyspnoea, low body mass index, or high healthcare utilization, as well as several multidimensional indices such as BODE, BODEx, CODEX, and HADO [15]. However, their ability to predict individual short- and medium-term survival is limited [18]. Consequently, specific tools have been developed, notably the NHPCO criteria [19] and the NECPAL CCOMS-ICO© method [20], which incorporates the “surprise question” (“Would you be surprised if this patient died in the next 12 months?”) together with clinical, functional, and symptom-burden criteria to more reliably identify patients at the end of life or with complex palliative needs.

In light of the variability and complexity of the COPD disease trajectory, an earlier approach focused on symptom burden, functional decline, and quality of life, rather than prognosis alone, is recommended. Referral should be based on specific needs, overcoming the so-called “prognostic paralysis” that hinders timely access to PC [21,22]. Both the American Thoracic Society [10] and the European Respiratory Society [23] emphasize that this approach improves patient-centred care. A Delphi document identified the lack of consensual criteria as the main barrier to referral to PC [24].

Taking the above into account, referral to PC should be considered in patients who meet criteria for advanced COPD. In addition, the presence of other concurrent factors that may reflect unmet needs should be assessed, such as persistent refractory symptoms (dyspnoea, anxiety, pain) despite optimized treatment, frequent emergency department visits without a clear trigger, marked and progressive functional decline, caregiver burden, or a positive “surprise question.” The presence of these factors adds severity to the advanced disease state and supports early referral to PC for symptom management, psychosocial support, and care planning, even when prognosis is not clearly defined.

In the case of ILDs, the absence of formal consensus has led to proposed definitions based on disease progression [25]: (1) worsening respiratory symptoms without an alternative cause; (2) a 5–10% decline in forced vital capacity (FVC) and/or a ≥10% decline in DLCO; and (3) radiological progression of fibrosis. The additional presence of respiratory failure, baseline dyspnoea mMRC 3–4, or frequent emergency department visits/hospitalizations in the context of a defined “ceiling of care” may act as surrogate markers of an advanced stage or terminal phase of the disease [25–27].

Patients with advanced ILD have complex needs that require a comprehensive approach. In advanced stages, symptoms such as dyspnoea and cough can be highly disabling, compounded by a significant emotional burden for both patients and caregivers [11]. Prognostic uncertainty promotes “prognostic paralysis,” delaying conversations about advance care planning and timely referrals to PC, a situation similar to that observed in COPD [21]. Only 10–20% of patients with ILD access PC services due to barriers such as lack of awareness of their benefits, the belief that they should be reserved for the very end of life, or the mistaken perception that they interfere with eligibility for lung transplantation [26,28].

Because ILD is less prevalent than COPD, few validated instruments exist to identify palliative needs. The GAP (Gender, Age, Physiology) index, initially developed for idiopathic pulmonary fibrosis and later adapted to ILD (GAP-ILD), constitutes a useful tool [29]. Based on sex, age, FVC, and DLCO, it stratifies patients into stages I–III, with stage III indicating a worse prognosis. Identifying patients in stage III facilitates planning of interventions focused on symptom relief, psychosocial support, and shared decision-making, thereby helping to guide referral to PC.

As in COPD, identifying patients with advanced ILD requires a needs-based approach combined with disease- and prognosis-related criteria [30,31]. Factors that support referral to PC include progressive fibrotic phenotypes, advanced and irreversible disease, age>70 years, frequent exacerbations, a usual interstitial pneumonia radiological pattern, and high functional dependence. Chronic respiratory failure and pulmonary hypertension also indicate poorer survival. Kalluri et al. [32] propose specific criteria which, combined with GAP-ILD staging, facilitate the identification of patients who may benefit from PC.

In summary, referral to PC should be considered in patients with progressive fibrotic disease, particularly those with chronic respiratory failure, frequent emergency department visits, pulmonary hypertension, or GAP-ILD stage III. As in COPD, the presence of refractory symptoms, functional decline, emotional distress, or unmet psychosocial needs justifies early referral, regardless of the estimated prognosis.

This document is the result of a strategic collaboration between the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Palliative Care (SECPAL), aimed at integrating the respiratory perspective and the palliative care approach in the management of advanced respiratory diseases. The synergy between both societies enables the harmonization of criteria, the updating of clinical practice, and the promotion of a multidisciplinary approach centred on the needs of patients and their caregivers.

For the development of these recommendations, a multidisciplinary panel composed of 15 experts representing both societies applied the SIGN (Scottish Intercollegiate Guidelines Network) methodology [33]. This methodology classifies scientific evidence from level 1++, corresponding to very high-quality clinical trials or systematic reviews, to level 4, based on expert opinion. Evidence levels 1++ and 1+ derive from well-designed experimental studies, whereas levels 2++ and 2+ correspond to observational studies of variable quality, and levels 3–4 reflect non-analytical evidence or consensus-based data. This hierarchy is translated into grades of recommendation A, B, C, and D, where grade A is supported by the strongest evidence (1++ or 1+), grade B by level 2++, grade C by level 2+ or 3, and grade D by limited studies or expert consensus. When sufficient evidence is lacking but clinical practice supports an intervention, Good Practice Points (GPPs) are issued as consensus-based recommendations. Details of the methodological process are provided in Supplementary Material 1.

Through this process, 70 recommendations were established across the following domains: management of respiratory symptoms in advanced chronic respiratory diseases (32 recommendations), improvement of quality of life and supportive care (15 recommendations), communication and family support (11 recommendations), and multidisciplinary coordination and integrated care (12 recommendations). Each recommendation was subsequently voted on using a Likert scale; in addition to the author panel, an external group of seven recognized experts in the field of severe chronic respiratory diseases was invited to participate. “Consensus” was defined as ≥75% of participants scoring 4 or 5 on the Likert scale, with “strong consensus” defined as ≥90%. Scores between 50% and 75% were interpreted as “majority agreement,” while lower values were considered “lack of agreement” [34]. In the expert panel voting, 46 recommendations achieved a consensus level above 90%, 17 achieved agreement between ≥75% and 90%, five scored between 50% and 75%, and two recommendations did not reach consensus and were classified as lacking agreement.

In addition, a systematic literature review was conducted and organized into six sections. Sections 2, 3, 4, and 5 generated recommendations strictly following the SIGN methodology, whereas section 1, of a conceptual nature, was developed through a narrative review. The systematic review was conducted in accordance with the PRISMA guidelines [35]. The search strategy was executed on 30 October 2025 through queries in the PubMed/MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO databases of the American Psychological Association (APA) (Supplementary Material 2). This strategy yielded a total of 3067 records, of which 133 original articles were selected to support the scientific rationale for the recommendations (Fig. 1). In the final phase, the panel was organized into six subgroups according to the clinical specialty of its members, allowing for a more specific and detailed analysis of the available evidence. Based on this collaborative work, the final recommendations were developed and subsequently reviewed and approved by all authors.

Fig. 1.

Study flowchart.

Gefapixant modulates activation of the cough reflex but frequently causes dysgeusia [75]. Its use in palliative care settings has been insufficiently studied.

Recommendation 27. Gefapixant may be considered only in patients with refractory chronic cough after careful assessment of the risk–benefit balance, and its routine use in palliative care should be avoided due to insufficient evidence. Level of evidence 2+; strength of recommendation C. Consensus (81%).

Psychosocial, nutritional, and rehabilitative interventions constitute an essential pillar of the comprehensive management of patients with advanced COPD and ILD. Their impact encompasses physical, emotional, cognitive, and social dimensions, directly influencing quality of life, coping with functional decline, and caregiver well-being.

Patients with advanced COPD and ILD present unpredictable clinical trajectories, high symptom burden, and prognostic complexity, generating specific communication needs for both patients and families [23,122,123]. The ERS guideline highlights psychosocial needs, support in decision-making, and difficulty in prognostic—or even diagnostic—estimation among the criteria for referral to palliative care [23]. Communication thus becomes a central pillar of the palliative approach (Fig. 4).

Fig. 4.

Integrative cycle of communication, education, and planning in advanced chronic obstructive pulmonary disease/interstitial lung disease.

Patients express a desire to receive honest prognostic information and perceive uncertainty in disease trajectory as a barrier to timely integration of a palliative approach [23,123]. Exacerbations are described as “traumatic” events, and particular value is placed on self-management education, early recognition of warning signs, rapid access to crisis resources, and post-exacerbation support [122]. In addition, patients highlight the need for early identification of poor-prognosis trajectories, in which timely referral to palliative care teams is critical [23,122].

Key barriers include stigma associated with the term “palliative care,” often perceived as cancer-related, and limitations imposed by mobility impairment and dyspnoea, which hinder access to specific resources, particularly in the absence of home-based programmes [23,122,123]. Dyspnoea support programmes and interventions targeting Activities of Daily Living (ADLs) have demonstrated functional improvement and are highly valued by patients [87]. The importance of coordination between primary and specialized care is also emphasized, as well as the negative impact of stigmatizing attitudes towards smoking [124].

In ILD, additional issues have been described: (1) discrepancy between preferred and actual place of death, with most deaths occurring in hospital settings [23,125]; (2) specific informational needs (oxygen therapy, signs of progression, prognosis) [23,126]; (3) high emotional burden, including anger [126]; and (4) Advance Care Planning (ACP) programmes have been shown to improve communication quality and are well received by patients [23,126,127].

Recommendation 48. Systematically explore information needs, fears, and expectations of patients and families, including prognosis and exacerbation management. Evidence 2+; Recommendation B. Strong consensus (100%).

Recommendation 49. Implement education and self-management programmes focused on exacerbations, warning signs, and available resources. Evidence 2+; Recommendation B. Strong consensus (100%).

Recommendation 50. Promote close coordination between primary care, hospital care, and palliative care teams to improve accessibility and continuity. Evidence 3; Recommendation D. Strong consensus (100%).

So-called “trigger moments” (disease progression, poor symptom control, hospitalizations, need for ventilation, ILD diagnosis) represent windows of opportunity to initiate deeper conversations about the clinical situation and future decisions [23]. For these scenarios, communication models such as SPIKES [128] have been adapted, and specifically in respiratory disease, the five-step framework proposed by Costa and Arranz and updated by Denizon et al. [129]: (a) STOP (and PRE-STOP): Plan time and setting, announce the content of the visit, and acknowledge one's own emotional state; (b) ASK: What the patient knows and what they wish to know; (c) VALIDATE: Listen to, accept, and legitimize the patient's experience and emotions; (d) INFORM: Use clear, progressive language, avoiding bluntness and employing “warning shots” before delivering bad news; (e) AGREE: Shared decision-making, next steps, and future review.

Recommendation 51. Use structured communication strategies (e.g., adapted SPIKES, STOP–ASK–VALIDATE–INFORM–AGREE model) during trigger moments. Evidence 3; Recommendation D. Strong consensus (95%).

Recommendation 52. Explicitly provide space for emotional expression, with systematic validation of patient emotions and experiences. Evidence 3; Recommendation D. Strong consensus (90%).

Shared Care Planning (SCP), or advance decision planning, is considered a core component of palliative care in COPD and ILD [23]. The Spanish Association for Shared Care Planning defines it as a communicative and deliberative process aimed at identifying values, preferences, and expectations, and facilitating present and future shared decisions. In COPD, evidence (although limited) indicates that SCP improves end-of-life communication, therapeutic relationships, and documentation of advance directives, without significant adverse emotional effects [127,130]. In ILD, SCP is additionally associated with a higher likelihood of death at home, more consistent with patient preferences [125,131]. Qualitative analyses highlight that SCP reduces feelings of isolation and increases patient participation in their own care process [131].

There is no single “optimal” time to initiate SCP; however, consensus exists that it should not be started during acute exacerbations, as patients prefer to engage in SCP during periods of clinical stability [23,130]. In COPD, some authors suggest addressing SCP in more advanced stages, when likely clinical scenarios are clearer [130]. In ILD, particularly following a diagnosis of idiopathic pulmonary fibrosis (IPF), earlier initiation—even at diagnosis—is recommended, given its faster and less predictable progression [23,131]. Minimum recommended content includes [126,127,130]: (a) preferred place of care and death; (b) limits of the “ceiling of care” (including NIV, ICU admission, etc.); (c) preferences regarding management of respiratory failure and palliative sedation; (d) preferred routes of drug administration; and (e) designation of a surrogate decision-maker.

Models such as the “e-pal ladder” of the LagunAdvance programme structure SCP into three phases (initial exploration, consolidation/planning, advanced phase) and emphasize integration of patient values and support networks [132].

Recommendation 53. Offer SCP to patients with advanced COPD and ILD during periods of clinical stability, using trigger moments as opportunities. Evidence 2−; Recommendation C. Consensus (86%).

Recommendation 54. Explicitly explore values, fears, preferences regarding place of care, and treatment limits, documenting decisions. Evidence 3; Recommendation D. Strong consensus (95%).

Recommendation 55. In ILD, particularly following a diagnosis of IPF, consider early initiation of SCP from early stages or even at diagnosis. Evidence 2−; Recommendation C. Consensus (86%).

Family caregivers fulfil multiple roles: information provision, direct care, promotion of adherence, patient advocacy, and emotional support [133,134]. Their burden is high and is associated with poorer health, increased stress, loss of independence, and relational conflicts [135–137]. High caregiver burden is linked to increased risk of hospitalization and mortality in frail patients [138]. Despite this, systematic detection and structured support for caregivers remain insufficient [58,139–142]. The most frequent needs include: (a) emotional support (anger, guilt, fear, helplessness, stress); (b) clear information about the disease, exacerbations, and available resources; (c) support in managing role changes and family dynamics; (d) respite time and self-care support; and (e) guided access to resources and support groups [58,122,140–143].

Tools such as the Zarit Burden Interview [144–146], SF-36 [144,147], CD-RISC [148], and Beck Anxiety and Depression Inventories [144,149] allow assessment of caregiver burden, quality of life, resilience, and emotional symptoms.

Recommendation 56. Systematically assess caregiver emotional burden and needs using validated instruments (Zarit, SF-36, CD-RISC, BAI/BDI). Evidence 2+; Recommendation B. Strong consensus (95%).

Recommendation 57. Include caregivers in education about the disease, exacerbations, and self-care, both in clinical visits and rehabilitation programmes. Evidence 2+; Recommendation B. Strong consensus (95%).

Recommendation 58. Facilitate access to psychological support resources, caregiver groups, and self-care strategies, promoting respite opportunities. Evidence 3; Recommendation D. Strong consensus (95%).

Advanced respiratory diseases (COPD, ILD, and other chronic respiratory conditions) are associated with high symptom burden (dyspnoea, cough, fatigue, anxiety, and depression), unpredictable clinical trajectories, and frequent transitions between care settings. The WHO and the Council of Europe recommend integrating palliative care into health systems to improve symptom control, quality of life, and decision planning [150,151]. However, the European Atlas of Palliative Care shows that implementation in respiratory diseases remains significantly lower than in other areas [152,153].

European scientific societies advocate for integrated models tailored to patient and family needs, initiating palliative care early and in parallel with disease-modifying treatment, rather than restricting it to the terminal phase of life [23,44,154]. This approach requires coordinated contributions from Pulmonology, Palliative Care, Primary Care (PC), Nursing, Physiotherapy, Psychology, Nutrition, Social Work, and other professionals.

Recommendation 59. Integrate palliative care early and in parallel with disease-specific treatment in patients with advanced respiratory disease. Evidence 2+; Recommendation B. Strong consensus (100%).

Recommendation 60. Ensure an interdisciplinary approach addressing physical, emotional, social, and spiritual dimensions of the patient and caregiving environment. Evidence 3; Recommendation D. Strong consensus (100%).

Effective collaboration relies on several structural strategies: (a) Joint clinics involving Pulmonology, PC, and Palliative Care, useful for managing complex symptoms and developing individualized care plans; (b) Regular multidisciplinary case discussion meetings for shared decision-making; (c) Integrated pulmonary rehabilitation programmes combining physical intervention, symptom management, and psychosocial support; (d) Specialized high-complexity units concentrating coordinated care for highly frail patients.

Additional recommended organizational tools include: (a) Shared electronic health records and remote communication channels; (b) Structured regular meetings with clear objectives and active participation; (c) Joint training sessions and workshops across specialties; (d) Case coordinators (typically advanced practice nurses or social workers) acting as liaisons between care levels; (e) Standardized protocols and clinical pathways defining roles, referral criteria, and key processes [20,152,155].

Recommendation 61. Implement shared electronic health records and structured communication channels (regular meetings, teleconsultation) between PC, Pulmonology, and Palliative Care. Evidence 3; Recommendation D. Strong consensus (100%).

Recommendation 62. Establish case coordinators (advanced practice nurses or liaison roles) to ensure continuity and coherence of care plans. Evidence 3; Recommendation C. Strong consensus (100%).

Recommendation 63. Develop agreed clinical pathways and protocols defining referral criteria, responsibilities, and care flows across settings. Evidence 3; Recommendation D. Strong consensus (100%).

Several studies have evaluated integrated models in advanced respiratory diseases:

• a)

  Integrated Pulmonology–Palliative Care multidisciplinary model: Monthly joint clinic with a multidisciplinary team [156]. This model resulted in a 52.4% reduction in emergency department visits, fewer in-hospital deaths (24.6%), high participation in advance care planning (84.8%), and improved control of dyspnoea and anxiety through non-pharmacological strategies and supervised morphine use (43.3%) [87].

• b)

  Home-based palliative care in advanced COPD: A pilot trial showing high acceptability (56% enrollment, 64% completion), a trend towards reduced hospitalization and improved perception of care, although without significant changes in quality of life; greater integration with PC and nursing training were highlighted as needs [157].

• c)

  Early joint Pulmonology–Palliative Care consultation: Review of PC records showed under-referral (only 15.4% of 1232 patients with prognostic indicators were receiving palliative care). Establishment of a multidisciplinary clinic increased referrals, interaction with specialist teams, and advance end-of-life planning [158].

• d)

  Respiratory rehabilitation with palliative care education: A randomized trial in COPD/ILD patients comparing conventional rehabilitation versus rehabilitation plus palliative care education. The experimental group showed significant improvements in knowledge about palliative care, perceived need for palliative care, willingness for early referral, and caregiver burden [159].

Overall, these studies suggest that integrated models can reduce emergency utilization, improve symptom control, facilitate advance care planning, and optimize resource use [150,156,160].

Recommendation 64. Develop joint Pulmonology–Palliative Care clinics, preferably involving Primary Care and other professionals, for patients with advanced respiratory disease. Evidence 2−; Recommendation C. Strong consensus (100%).

Recommendation 65. Promote home-based palliative care programmes coordinated with Primary Care for patients with advanced COPD who present high frailty or mobility limitations. Evidence 2−; Recommendation C. Strong consensus (100%).

Recommendation 66. Integrate palliative care content into respiratory rehabilitation programmes to improve knowledge, acceptance, and early referral to palliative care. Evidence 1−; Recommendation B. Strong consensus (95%).

An integrated respiratory palliative care model should be flexible, patient-centred, and adaptable to prognosis and local organization (Fig. 5). Its core components include: (1) Accessibility and early identification; (2) Use of palliative needs screening tools (e.g., NECPAL) [20]; (3) Early identification from Primary Care and hospital settings, leveraging recurrent admissions:

• a)

  Multidimensional assessment: Shared physical, psychological, social, and spiritual evaluation of the patient and caregiving environment by PC, hospital teams, and specialized palliative care teams when required [161].

• b)

  Integrated care pathway: A structured itinerary including identification, initial assessment and therapeutic goals, care planning (outpatient, home-based, telemedicine), periodic reassessment, coordination across settings, discharge planning, and continuity in the community [162,163].

• c)

  Care settings and resources: General resources include PC, Pulmonology and Internal Medicine/Geriatrics services, acute hospitals, day hospitals, hospital-at-home services, short-stay units, and medium–long stay facilities [164,165].

• d)

  Specialized palliative care resources: Hospital and home-based palliative care teams, palliative care units, and hospice-type models [155].

• e)

  Coordination structures: Telemedicine devices and programmes enhancing continuity and out-of-hours responsiveness [166].

• f)

  Case managers and complexity care units: Shown to be beneficial in other diseases (e.g., ALS) and transferable to advanced ILD and COPD [167].

• g)

  Coordination with Social Services: To address dependency and socioeconomic needs [168].

• h)

  Minimum shared data sets for continuity of care: Defined in consensus tables (diagnosis, stage, NECPAL, clinical summary, care plan, advance decisions, therapeutic agreement), accessible across all care levels [20].

Fig. 5.

Resources for the management of patients with advanced chronic respiratory disease. Abbreviations. HaH: hospital at home. SSU: short-stay unit. PCU: palliative care unit.

Recommendation 67. Apply screening tools (such as NECPAL) for early identification of patients with palliative care needs in advanced respiratory disease. Evidence 2−; Recommendation C. Strong consensus (100%).

Recommendation 68. Implement integrated care pathways with clear referral criteria, multidimensional assessment, and coordinated follow-up across Primary Care, hospital, and Palliative Care. Evidence 3; Recommendation D. Strong consensus (100%).

Recommendation 69. Incorporate telemedicine, hospital-at-home services, Pal 24, or INNOPAL-type projects to improve continuity, reduce emergency visits, and prevent avoidable admissions. Evidence 2−; Recommendation C. Strong consensus (95%).

Recommendation 70. Use shared minimum clinical data sets to ensure consistency in decision-making across care levels. Evidence 3; Recommendation D. Strong consensus (95%).