It is important for oncologists who provide comprehensive cancer care to be familiar with the principles of primary palliative care and interdisciplinary team–based approaches to palliative care. Palliative care is a medical subspecialty that provides specialized care to individuals with serious illnesses, with a primary focus on providing symptom relief, pain management, and relief from psychosocial distress, regardless of diagnosis or prognosis. Ideally, palliative care is provided by a team of physicians, nurses, social workers, psychologists, and chaplains. The core of palliative care is addressing, in depth, the physical, emotional, and spiritual suffering that a patient can experience. Palliative care is a key component of oncologic care, and we highly recommend that it be integrated into the plan of care for patients with advanced cancer. Early integration of palliative care has been shown to provide improved outcomes in patients with advanced cancer. This article reviews the ways in which palliative care and oncology teams can collaborate to provide high-quality care to patients and their families; it also provides practical tips for oncologists who wish to initiate primary palliative care for their patients. Prior to referral to a specialized interdisciplinary palliative care team, oncologists may start advance-care planning discussions, provide basic pain and non-pain symptom relief, and utilize assessment tools. If a specialized palliative care team is not available, the oncologist will often address additional aspects of palliative care, with assistance from social work departments and other resources in the community.
What Is Palliative or Supportive Care?
Palliataive care is a medical subspecialty that provides care for people with serious illnesses; its primary focus is on providing symptom relief, pain management, and relief from stress, regardless of diagnosis and prognosis. The American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology, and the National Comprehensive Cancer Network all support the integration of palliative or supportive care with the practice of oncology.[2-4] Early integration of palliative care at the time of an advanced cancer diagnosis enhances patient care.
Palliative care ideally is provided by an interdisciplinary team that should include a physician, nurse, social worker, and chaplain. Palliative care teams often include or work closely with other specialists, such as physical or occupational therapists, psychologists, nutritionists, acupuncturists, music therapists, and massage therapists. Palliative care is a holistic, team approach to patient care, addressing patients’, and their caregivers’, physical, emotional, practical, and spiritual needs. Oncologists often feel that they are able to provide palliative care for their own patients. Indeed, they may be able to succeed in medical symptom management; however, true palliative care addresses more than just physical suffering because it is delivered by an interdisciplinary team that focuses on various aspects of care and quality of life.
The 2017 ASCO guidelines recommended that any patient with advanced cancer—inpatient or outpatient—should receive dedicated palliative care services, ideally earlier in the disease course, concurrent with active treatment and within the first 8 weeks of diagnosis. Cancer symptoms and side effects from treatment require additional management. Patients may receive palliative care at any stage of illness, and it is appropriate for patients of any age with cancer or other noncancer advanced illnesses. Palliative care can be given along with aggressive treatment; patients can receive chemotherapy or radiation therapy or undergo surgical procedures while also receiving palliative care. In fact, studies have shown that starting palliative care earlier provides better quality of life and may extend survival. Palliative care teams focus on building relationships and rapport with patients and their families over time, while also addressing symptoms, emotional needs, and functional abilities. The palliative care team educates the patient and his or her family about the illness and prognosis, and clarifies goals of care.[6,8]
A Cochrane review examined seven studies of early palliative care interventions vs standard cancer care that compared health-related quality of life, depression, symptom management, and survival. Of these seven studies, five were prospective randomized controlled trials, and the remaining two were cluster randomized trials. A randomized controlled trial conducted by Temel et al showed that early integration of palliative care along with standard oncologic care in patients with non–small-cell lung cancer resulted in a prolongation of survival of approximately 2 months and a clinically meaningful improvement in quality of life and mood. Otis-Green et al studied patients at all stages of non–small-cell lung cancer and found that quality-of-life improvements were greater in patients with early- vs late-stage disease states. The ENABLE III trial by Bakitas et al studied an intervention by specialty nurses in an outpatient setting in a mixed cancer population, and found that the intervention led to patient education and empowerment. However, it also demonstrated that studying a patient population for only 3 months and delaying the palliative care intervention resulted in insignificant improvement in quality-of-life scores and symptom intensity. Maltoni et al conducted a prospective randomized study of patients with metastatic or locally advanced inoperable pancreatic cancer. This study on the impact of early palliative care, in addition to standard cancer care, revealed lower symptom intensity in the early palliative care group at 3 months, as well as a higher quality of life. These studies provide moderate evidence of improved survival with early intervention carried out in an ambulatory palliative care setting, as well as improvements in advance care planning, healthcare utilization, planned discharge, and decreased emergency room visits, with better hospice utilization.
How Does Palliative Care Differ From Hospice Care?
A common misunderstanding is that palliative care is the same as hospice care. While both services follow an interdisciplinary approach, and address physical, emotional, and spiritual well-being, there are important differences. Palliative care is provided at any point of a chronic disease, with the goals of providing comfort, quality of life, and support to patients and their families. While the goal of hospice care is also symptom relief, a key difference is the patient’s prognosis and goals of care. Hospice care provides comfort without a curative intent, when there are no longer curative options available or when a patient has chosen not to pursue curative or aggressive treatment because the side effects outweigh the benefits.
Eligibility for hospice care requires that two physicians certify that a patient has less than 6 months to live, if the disease were to follow its natural progression. In contrast, palliative care can begin at any time and at any stage of illness, terminal or not, at the discretion of the physician and patient.
Hospice services can be paid for by Medicare, Medicaid, or private insurance. The covered services include medications related to the diagnosis that led to hospice care, as well as medical equipment; 24/7 phone access to care; nursing, physician, chaplain, and social service visits to the home; and bereavement support following a death. Hospice care is typically delivered at home or in facilities such as nursing homes and assisted-living residences, but can also be delivered in hospitals.
What Can Palliative Care Provide to Your Patients?
Successful palliative care teams complement oncologic care. Palliative care teams are able to take more time with patients and their families to provide a comprehensive baseline assessment and follow-up assessments that include evaluation of quality of life, as well as of physical, psychological, spiritual, and social domains. They can also assist with disclosure of prognosis. This team-based approach ensures that patients experience a smooth transition from the hospital to other services, such as home care or nursing home facilities.
Palliative care reduces suffering and distress among patients and families at any stage of disease. It can be especially beneficial to patients who have:
• Multiple comorbidities.
• Recurrent infections.
• Nonhealing wounds or need for wound care.
• A history of recurrent hospitalizations.
• High levels of suffering and psychosocial, emotional, or spiritual distress.
• A need for coordination of care.
Additional benefits of palliative care are listed in Table 1.
How Can Oncologists Provide Palliative Care Services During Their Visits?
Despite the increase in fellowship-trained palliative care physicians, their numbers still do not meet current patient demand. A 2011 study showed that there was 1 oncologist for every 141 newly diagnosed cancer patients in the United States, but only 1 palliative medicine physician for every 1,200 persons living with a serious or life-threatening illness. Therefore, it remains crucial for all healthcare providers to receive training in basic palliative care skills since it is not feasible for all patients with cancer to be cared for by palliative care teams.
Assessing for and managing physical symptoms that are a result of a cancer diagnosis or a side effect of treatment helps improve a patient’s quality of life. Additional palliative care services and skills that can be provided by the oncology team are listed in Table 2.
Common palliative care principles that oncologists can adopt include improving symptom assessment and management by using patient and family goals vs problem-focused care as the guiding principle; improving understanding of prognosis and delivering prognosis information with compassion and empathy; and recognizing that spiritual, psychosocial, and cultural elements play a relevant role in causing suffering for patients with serious illnesses.
How to Effectively Communicate With Your Patients
In addition to providing symptom management to patients, an important goal of palliative care is to assist patients with advance care planning. Communication is a foundation of palliative care, and nowhere are good communication skills as important as they are in discussions of advance directives and goals of care.
Studies show that patients with chronic illness want to talk about their choices and goals of care, as well as have frank discussions about prognosis in the disease trajectory. Patients usually prefer that their oncologists and primary care physicians initiate conversations regarding advance directives and goals of care. Involvement of the primary healthcare provider is essential, since no one is better suited to discuss patients’ goals, desires, and quality-of-life outcomes than the physician who knows the patient best and has the patient’s and family’s trust.
It is best to assess a patient’s and family’s readiness for a conversation first and to explore their understanding of the disease and its likely course, as well as treatment options. The “ask, tell, ask” method of communication is well documented and suitable for any type of communication. This strategy elicits the patient’s understanding of his or her situation and allows the clinician to assess the patient’s knowledge base, education level, emotional state, and misperceptions. It is helpful to deliver information in a clear, concise, and easy-to-understand manner, divulging information in small doses to help the patient process it. It is also important to inquire about the patient’s understanding of the information and, if needed, to ask him or her to restate what was said. Patients often respond favorably if the physician asks what is important to them and explores their values and goals.
1. Rangachari D, Smith TJ. Integrating palliative care in oncology: the oncologist as a primary palliative care provider. Cancer J. 2013;19:373-8.
2. 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;30:880-7.
3. Schrijvers D, Cherny NI; ESMO Guidelines Working Group. ESMO Clinical Practice Guidelines on palliative care: advanced care planning. Ann Oncol. 2014;25(suppl 3):iii138-42.
4. Dans M, Smith T, Back A, et al. NCCN guidelines insights: palliative care. Version 2.2017. J Natl Compr Canc Netw. 2017;15:989-97.
5. Bakitas M, Lyons KD, Hegel MT, Ahles T. Oncologists’ perspectives on concurrent palliative care in a National Cancer Institute-designated comprehensive cancer center. Palliat Support Care. 2013;11:415-23.
6. Ferrell BR, Temel J, Temin J, Smith T. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline update. J Clin Oncol. 2017;35:96-112.
7. Salins N, Ramanjulu R, Patra L, et al. Integration of early specialist palliative care in cancer care and patient related outcomes: a critical review of evidence. Indian J Palliat Care. 2016;22:252-7.
8. Bickel K, McNiff K, Buss M, et al. Defining high-quality palliative care in oncology practice: an ASCO/AAHPM guidance statement. J Clin Oncol. 2016;12:828-38.
9. Haun MW, Estel S, Rücker G, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6:CD011129.
10. Temel J, Joseph G, Muzikansky MA, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med. 2010;363:733-42.
11. Otis-Green S, Sidhu RK, Del Ferraro C, Ferrell B. Integrating social work into palliative care for lung cancer patients and families: a multi-dimensional approach. J Psychosoc Oncol. 2014;32:431-46.
12. Bakitas MA, Tosteson TD, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33:1438-45.
13. Maltoni M, Scarpi E, Dall’Agata M, et al. Systematic versus on-demand early palliative care: a randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life. Eur J Cancer. 2016;69:110-8.
14. Meier DE, Brawley OW. Palliative care and the quality of life. J Clin Oncol. 2011;29:2750-2.
15. Meier DE, 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. 2011. http://reportcard.capc.org/pdf/state-by-state- report-card.pdf. Accessed February 28, 2018.
16. Palliative Care Principles Primary Care Physicians Should Know. AHC Media. https://www.ahcmedia.com/articles/64540-palliative-care-principles-prima....
17. Back AL, Arnold RM, Baile WF, et al. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005;55:164-77.
18. Kaplan M. SPIKES: a framework for breaking bad news to patients with cancer. Clin J Oncol Nurs. 2010;14:514-6.
19. Baile WF, Buckman R, Lenzi R, et al. SPIKES: a six step protocol for delivering bad news. Oncologist. 2000;5:302-11.
20. Campbell S. Atul Gawande’s 5 Questions to Ask at Life’s End. Next Avenue. http://www.nextavenue.org/atul-gawandes-5-questions-ask-lifes-end. Accessed February 28, 2018.
21. Quill T, Robert A, Back A. Discussing treatment preferences with patients who want everything. Ann Intern Med. 2009;151:345-9.
22. Anwar S, Case A. The art of prognostication in advanced cancer: missing the big picture. J Fam Med. 2016;3:1050.
23. Hancock K, Clayton JM, Parker SM, et al. Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review. Palliat Med. 2007;21:507-17.
24. Weeks JC, Cook EF, O’Day SJ, et al. Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA. 1998;279:1709-14.
25. Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14:17-23.
26. Palliative Care Network of Wisconsin. Fast facts and concepts. https://www.mypcnow.org/fast-facts. Accessed February 28, 2018.
27. American Academy of Hospice and Palliative Medicine. http://aahpm.org. Accessed February 28, 2018.
28. Center to Advance Palliative Care. https://www.capc.org. Accessed February 28, 2018.
29. 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;302:741-9.
30. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168:1783-90.
31. Wright AA, Keating NL, Balboni TA, et al. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol. 2010;28:4457-64.