Integration of palliative care into standard oncology care
· Palliative care can be described as specialized medical care for patients with serious illnesses, and it focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness, regardless of the diagnosis.
· Palliative care focuses on the physical and psychological consequences of treatment.
· The American Society of Clinical Oncology (ASCO) recently published a provisional clinical opinion addressing the integration of palliative care into standard oncology care.
· To implement palliative care, clinicians are encouraged to: routinely ask their patients about their quality of life; explain palliative care; consider a referral for early palliative care; routinely discuss their patient's future and prognosis; encourage patients to prepare for sudden problems; establish a durable medical power of attorney; and help patients and their families prepare for end-of-life care.
Palliative care, concurrent with standard oncological care, should be considered early in the course of illness for any patient with metastatic cancer or high symptom burden.1 Palliative care can be described as specialized medical care for patients with serious illnesses, and it focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness, regardless of the diagnosis. Both the patient and the patient's caregivers benefit when treatment addresses the whole patient, and not just the disease. Palliative care focuses on the physical and psychological consequences of treatment. The significant suffering of patients and their families can be effectively addressed by modern palliative care teams.2
The American Society of Clinical Oncology (ASCO) recently published a provisional clinical opinion addressing the integration of palliative care into standard oncology care.1 This opinion states that patients with metastatic non-small cell lung cancer should, at initial diagnosis, be offered concurrent palliative care and standard oncologic care. Additionally, ASCO recommends this combination of care early in the course of illness for any patient with metastatic cancer or with high symptom burden.
To implement palliative care, clinicians are encouraged to do the following with their patients: routinely ask their patients about their quality of life; explain palliative care; consider a referral for early palliative care; routinely discuss their patient's future and prognosis; encourage patients to prepare for sudden problems; establish a durable medical power of attorney; and help patients and their families prepare for end-of-life care.3
BENEFITS FROM PALLIATIVE CARE
Conversations about palliative care have increased since Temmel and colleagues published results of their findings in the 2010 New England Journal of Medicine articles about a randomized trial of patients with metastatic non-small cell lung cancer.4 These newly diagnosed patients were assigned to either early palliative care integrated with standard oncologic care, or standard oncologic care alone. Notably, those receiving early palliative care had significant improvements in their quality of life and in their mood. Also, the patients receiving palliative care had less aggressive end-of-life care, yet had an average of 2.7 months of longer survival.
Early involvement of palliative care has not demonstrated excessive costs or harm to patients or caregivers in any trial to date.1 Additionally, studies have shown improved outcomes at costs that were lower than that of standard oncologic care only.1,5,6 A randomized, controlled trial of advanced cancer patients focused on the outcomes from nurse-led palliative intervention using a case management educational approach, and found that the patients had higher scores for quality of life and mood. However, the trial did not find any improvements in symptom intensity, reduced days in the hospital or intensive care unit, or decreased visits to the emergency department.7
A recent study on integrating palliative care into the outpatient, private practice setting found that this reduced patients' symptom burden, and provided a service that overwhelmingly satisfied the oncologists.8 Each time the palliative care team was consulted, the oncologists saved an average of 170 minutes per palliative care referral. Over time, this leads to an impressive amount of time saved and increased potential to see new patients, which could potentially increase revenue for the practice. Additionally, this integration provides quality care to patients who received assistance in managing their symptoms, while allowing oncologists to spend time evaluating new patients, determining study protocol regimens, and administering chemotherapeutic agents.
When oncologists are engaged in providing palliative care to their patients, this helps to address the scarcity of information and understanding that patients and their families experience, and also leads to improved patient trust.3
OBSTACLES TO INCREASING PALLIATIVE CARE
The expansion of palliative care services is limited due to the lack of palliative medicine physicians, as there is only one palliative medicine physician for every 1,200 persons living with a serious or life-threatening illness. This shortage has two main causes. First, palliative medicine is a fairly new specialty, only formally recognized in 2007. Second, Medicare funding, which supports the majority of residency training for physician specialties, does not support training for those specializing in palliative medicine.9
Access to palliative care services is primarily available in hospital settings, along with a few major medical centers that have outpatient or home-delivered palliative care programs. The business model for palliative care is based on cost avoidance instead of revenue generation, which is an unusual model in health care. For this model to be successful, it requires sophisticated analytic methods, which does not fit into the current operating metrics of hospitals. Also, current accreditation standards do not require a palliative care program at hospitals and nursing homes, therefore, it is not high on the list of priorities.9
Misperceptions and lack of information continue to abound regarding palliative care. Physicians tend to view palliative care as an option when there is nothing more that can be done for the patient's disease, rather than seeing it as a simultaneously delivered addition to treatments focused on the disease.2 A survey of physicians found much resistance to seeing palliative care as other than “hospice” or “end of life.”10 Health care providers need to recognize the benefits of palliative care and communicate these benefits to both patients and their families.3
Additionally, most patients and their families lack the understanding of palliative care services and of what it offers. Once informed, they are extremely positive about palliative care and want access to this care if they need it.10
Conversations with patients about palliative needs are still occurring too infrequently, and too late in the course of their diseases. For patients with advanced or incurable cancer, realistic conversations about options and alternatives should occur throughout the course of the patient's illness. These crucial conversations allow oncologists to match the patient's goals with the actual care delivered.11
Open and honest communication, medically appropriate goal setting, and symptom management are the key points of palliative care, as describe by the ASCO provisional clinical opinion.1 They suggest that a good working list of components for palliative care could include describing the diagnosis and frankly discussing the prognosis and curability of the disease; explicitly discussing the medically appropriate goals of treatment, using a standardized symptom assessment tool to guide symptom management; assessing and supporting the patient's psychosocial well-being; and involving hospice early in the remaining lifetime of patients with life-ending illnesses. Research is ongoing to establish the essential components of concurrent, standard oncologic care and palliative care based on the growing needs for this type of patient care.
1. Smith TJ, Temin S, Alesi ER, et al. American society of clinical oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880-887.
2. Kelley AS, Meier DE. Palliative care — a shifting paradigm. N Engl J Med. 2010;363(8):781-782.
3. Kirch RA, Brawley O. Palliative care: A lifeline to quality of life [published online ahead of print February 7, 2012]. J Oncol Practice. doi:10.1200/JOP.2011.000530.
4. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
5. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.
6. Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180-190.
7. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741-749.
8. Muir JC, Daly F, Davis MS, et al. Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manage. 2010;40(1):126-135.
9. Morrison RS. America's care of serious illness: a state-by-state report card on access to palliative care in our nation's hospitals. Center to Advance Palliative Care. J Palliat Med. 2011;14(10):1094-1096. http://reportcard-live.capc.stackop.com/pdf/state-by-state-report-card.pdf. Accessed March 16, 2012.
10. Center to Advance Palliative Care. 2011 public opinion research on palliative care. http://www.capc.org/tools-forpalliative-care-programs/marketing/public-opinion-research/2011-public-opinionresearch-on-palliative-care.pdf. Accessed March 16, 2012.
11. Peppercorn JM, Smith TJ, Helft PR, et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol. 2011;29(6):755-760.