The authors provide a timely review of the components of hospice/palliative care programs and an informative historical perspective on the development of these programs overseas and in the United States. They also review the current mechanisms that fund hospice care and explain how the skills for delivering hospice/palliative care have been incorporated into oncology education at Northwestern University. This articles highlights the many positive aspects of hospice programs, which currently provide expert multidisciplinary care by committed and knowledgeable professionals to almost 30% of patients with cancer in this country. However, the discussion should serve to focus attention on several additional aspects of the symptomatic care of patients with cancer.
Separate Hospice/Palliative Care Programs
As the authors of this review and others have stressed, there is no doubt that hospice and palliative care programs are good for patients and their family members. These programs provide outstanding services tailored to the physical and emotional needs of patients, families, and caregivers that often substantially affect the dying process. However, there is a price to separating professionals who are interested and skillful in palliative care from other oncologists. The arbitrary division of this specialty into those who "treat symptoms" and those who "treat tumors" can send unfortunate messages to patients, family members, nurses, practicing physicians, fellows, house officers, and students. For example, the increasing emphasis on separate hospice and palliative care programs fosters the notions that (1) palliative care, including pain control, is too complicated to be managed by most physicians or oncologists and should be left to specialists, and (2) symptom control is less important if you are trying to cure the patient or control disease progression through therapy.
To the contrary, excellent symptom control can and should be provided by all oncologists and should be equally available to cancer patients during all phases of their illness. The management of pain in patients who present with a new malignancy or who are in the midst of antineoplastic therapy requires the same determination, skill, and energy as it does in the terminal state. Palliative care specialists should be available to oncologists for difficult cases, just as experts in infectious disease and endocrinology are needed for particularly complicated infections or treatment-resistant hypercalcemia. However, we must not forget that the skills required to ensure the comfort of patients with cancer or ease them through the dying process are integral facets of an oncologist's responsibility. The challenge, as the authors note, is to determine how to effectively integrate these skills into the education of oncologists.
The Managed-Care Era
The authors also point out that hospice care was one of our nation's first attempts at managed care. Now, 13 years after the US Congress passed the Medicare Hospice Benefit and a decade into the rapid growth of managed care in the United States, it is clear that the capitated approach to the provision of health care is not all positive. A fixed reimbursement of as little as $100 per patient per day to a hospice makes it difficult to order appropriate but expensive diagnostic or therapeutic approaches. Thus, patients with advanced cancer and back pain may receive glucocorticoids and opioids rather than an MRI and radiotherapy for an impending spinal cord compression, even though the latter would likely lead to optimal pain control, preservation of neurologic function, and an improved quality of life. Although these choices are certainly appropriate in some instances, they are clearly inappropriate in others.
Ultimately, excellence in palliative care must be woven into the fabric of oncologic practice and should be available to all patients at all stages of their disease. Oncologists must be trained to deal with pain in newly diagnosed patients and the emotional and family needs of dying patients. In fact, these must be high priorities for physicians, who know that most of their patients will ultimately succumb to their malignancy. The transition from conventional to hospice care should be smooth, so that patients and families are not forced to change physicians during this stressful time. In addition, patients should receive appropriate diagnostic studies and therapeutic modalities to allow them to die comfortably and with dignity even in a capitated reimbursement environment.