Palliative Care Integration and Expertise Are Pressing Goals for Oncologists
There is still more work to be done to ensure that palliative care is understood.
Early palliative care interventions can substantially improve cancer and cancer treatment-associated effects to the quality of life and psychological well-being of patients and family members, including patient pain, mobility impairment, shortness of breath, nausea and vomiting, anxiety, and depression.
There is even evidence that early integration of palliative care in advanced cancer treatment can prolong survival time by more than 2 months in some cases. But implementation of early palliative care in clinical oncology has been slow. New payment reforms proposed by the American Society of Clinical Oncology (ASCO) would remove one important barrier to implementation by allowing bundled reimbursements.
The majority of patients with cancer receive palliative care only in their last days of life, if at all. Attitudes among clinicians, patients, and family members still commonly and mistakenly equate palliative care with end-of-life hospice or surrender—something to be undertaken only after all efforts to prolong life, have failed.1,2 Political rhetoric surrounding health insurance reform has fueled some people's concerns that palliative care and advanced care planning for patients with terminal disease.3
In reality, palliative care simply refers to interventions aimed at alleviating the effect of disease and treatment on the well-being and quality of life of patients and their family members.4,5
Patients with advanced cancer commonly suffer marked fatigue and weakness, loss of appetite and energy, pain and emotional stress, which can profoundly affect their quality of life.6
Research indicates that initiating supportive care earlier, such as upon diagnosis with metastatic disease, can improve patients' quality of life, pain, and mobility.4,6,7 There is even evidence that, among patients with terminal lung cancer, immediate initiation of palliative care can prolong median survival times by 2.7 months.4,7
Such findings led ASCO to issue a 2012 provisional clinical opinion recommending the integration of palliative care services into standard cancer care upon diagnosis with metastatic or advanced cancer.1 According to ASCO, physicians should regularly update patients about their prognosis and ask them about their quality of life and symptoms like fatigue, pain, and anxiety immediately upon diagnosis. Physicians should also explain the purpose of palliative care right away.1
Now, more than 2 years later, ASCO's recommendation for early integration of palliative care has yet to be comprehensively implemented, and referrals continue to be made primarily near the end of patients' lives.8,9
Truly patient-centered care requires the empowerment of patients with information and a role in clinical decision-making. Clinicians should not assume that patients will resist discussing palliative care, including psychosocial support, at the time of diagnosis instead of waiting until the end of life. A key message that must be conveyed to patients with cancer is that palliation does not mean end of life.
Barriers to early integration abound. Medicare does not pay to train palliative specialists, leaving too few experts. (Two bills currently before Congress would address training and the development of palliative care centers.)
Also, Medicare does not reimburse oncologists or practices that perform palliative care outside of the context of end-of-life hospice care, explained Jeffery Ward, MD, chair of ASCO's Payment Reform Workgroup. That means that practices sometimes go unreimbursed for the time and effort they invest in supportive care for their patients.
Dr. Ward's workgroup recently proposed Medicare oncology payment reforms that would streamline billing (reducing the current 58 cancer care billing codes to just 11 bundled-care codes) and reimburse oncology practices for integrating palliative care at the time of diagnosis.10