Supportive and Palliative Care in Cancer Patients
Supportive and Palliative Care in Cancer Patients
The term "supportive oncology" refers to those aspects of medical care
concerned with the physical, psychosocial, and spiritual issues faced
by persons with cancer, their families, their communities, and their healthcare
providers. In this context, supportive oncology describes both those interventions
used to support patients who experience adverse effects caused by antineoplastic
therapies and those interventions now considered under the broad rubric of palliative
care. At its core, palliative care is concerned with providing the maximum
quality of life to the patient/family unit.
Definitions and Evolution
In 1990, the World Health Organization (WHO) published a landmark document, Cancer Pain Relief and Palliative Care, that clearly defined the international barriers and needs for improved pain and symptom control in the cancer patient. The WHO defined palliative care as: ...the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of illness in conjunction with anti-cancer treatment. In 1995, the Canadian Palliative Care Association chose a somewhat broader definition that emphasizes a more expanded role of palliative care by combining it with curative therapy: Palliative care, as a philosophy of care, is the combination of active and compassionate therapies intended to comfort and support individuals and families who are living with a life-threatening illness. During periods of illness and bereavement, palliative care strives to meet physical, psychological, social and spiritual expectations and needs, while remaining sensitive to personal, cultural and religious values, beliefs and practices. Palliative care may be combined with therapies aimed at reducing or curing the illness, or it may be the total focus of care. Clearly, palliative care has developed into a recognized discipline. In the United States, palliative care is rapidly evolving in parallel with a well-established hospice model. The US version of hospice remains a critically important part of this broader approach to palliative care, which attempts to help patients and their families deal with quality-of-life issues throughout the trajectory of illness, even when treatment has curative intent. Palliative care is an emerging health-care specialty with national boards, newly accredited fellowships in 2004, and National Consensus Clinical Practice Guidelines; it is an important part of the medical community's response to the needs of patients and families throughout the trajectory of serious and life-threatening illness-relief from their suffering, even while they receive therapies aimed at curing their cancer. Ending the Either/Or Dilemma: A Multidisciplinary Approach
Just as health is more than the absence of illness, so too is palliative care much more than the absence of disturbing symptoms. The fundamental mission of palliative care undoubtedly reflects the underpinnings of Dame Cicely Saunders, who pioneered the coordinated an interdisciplinary approach of physical, emotional, and spiritual symptom management at the end of life. However, since the introduction of this philosophy of care in the United States, end-of-life hospice/ palliative care has been driven by the restrictions dictated by the bureaucracy of Medicare reimbursement regulations, life expectancy projections, and the unilateral choice of services based on "either" often-fragmented curative aggressive treatment "or" coordinated interdisciplinary comfort care. Although the literature reports that there is high patient and caregiver satisfaction with the interdisciplinary approach to end-of-life care and symptom management, statistics reveal that these restrictions have significantly impacted willingness to utilize this scope of services, as patients would be required to make the "either/or" decision that often compromises their need to retain hope for cure or prolonged prognosis. All health-care clinicians have the ethical responsibility to "first do no harm" by alleviating the patient's burden of the dilemma of having to choose either aggressive treatment or comfort care, and hence physically supporting their need for hope-something that is so vital to human existence. Humanism in health care can be initiated by integrating palliative care into mainstream medicine, both within general practice and across all specialty settings. Valuing quality-of-life symptom management should not occur just at the end of life, but should be aggressively implemented from the onset of chronic disease diagnosis and throughout every day that the patient lives with the illness that may eventually lead to death. Throughout the disease trajectory a patient requires both "high-tech" and "high-touch" care. This multidimensional and interdisciplinary approach meets clinical, scientific, and functional needs with compassion. Integrating palliative care with curative disease-oriented therapy requires a focus on communication and collaboration with the primary treatment team. The concept of a palliative care team can be valued as an extension of the primary team. This collaboration is best established by frequent direct contact with the primary treating team and consistent hands-on bedside teaching. Back-to-basics "bedside care" establishes a sense of physical presence, provides the opportunity to teach by example, enhances continuity of care for the patient, and helps to diminish an adversarial or competitive feeling between consultative and treating teams. All parties attain a sense of contribution and the patient benefits by the comprehensive coordination of care. The essence of palliative care is to provide a "win-win"forum, whereby the patient receives optimum symptom management to ensure quality of life, and the primary team members concentrating on the cancer itself feel supported during the chosen treatment regime throughout the patient's disease trajectory. Fundamental Patient Concerns
Even when cancer can be effectively treated and a cure or life prolongation is achieved, there are always physical, psychosocial, or spiritual concerns that must be addressed to maintain functions and optimize quality of life. For patients where cancer cannot be effectively treated, palliative care must be the dominant mode and one must focus intensively on the control of distressing symptoms. Planning for the end of life and ensuring that death occurs with a minimum of suffering and in a manner consistent with the values and desires of the patient and family are fundamental elements of this care. A recent commentary in the Journal of the American Medical Association discussed the inadequacy of clinical education and the need to better prepare practitioners to treat chronic disease. Palliative care, when integrated with the curative model, helps to ensure the continuity and integration of care that is so essential to the patient and family suffering with a cancer diagnosis. Palliative care, as a desired approach to comprehensive cancer care, is appropriate for all healthcare settings, including the clinic, acute care hospital, long-term care facility, or home hospice. Clinicians and health-care environments throughout the United States have viewed palliative care as being specifically for pain or end-of-life care. This is a critical barrier that must be overcome. Palliative care is clearly not only for pain or end-of-life care. In this special issue of ONCOLOGY, an attempt has been made to discuss several important symptoms that an individual may experience during the course of their cancer trajectory. These symptoms include depression, delirium, fatigue, and pain. Clearly, this special issue is only a beginning-an introduction to a small part of palliative care. An individual with cancer can experience many different physical, psychological, social, and spiritual symptoms. The goal of palliative care is to help relieve all of these symptoms: to relieve suffering and improve quality of life. The vision is to successfully balance a humanistic, bedside-oriented, holistic philosophy of care and combine it with a rigorous scientific curative approach. Palliative care is best able to help integrate high-tech and high-touch care for an individual with cancer.
The strength of palliative care includes the following aspects:
- Interdisciplinary assessment, intervention, and collaboration to improve quality of life during aggressive treatment
- Integration of complementary modalities to treat physical, emotional, and spiritual suffering
- Intervention not limited to pain management or end-of-life care
- Optimal outcomes achieved by early initiation and continued implementation throughout the disease trajectory
- Aggressive research and palliative care treatment modalities that share and respect parallel pathways to seek cure, maximize quality of life, and restore hope within the realism of the patient's situation
- A multidimensional approach that meets clinical, scientific, and functional needs with compassion
There are many promising new cancer treatments on the horizon. No matter what these new treatments will offer in terms of curing the disease or prolonging life, cancer will remain a devastating illness not only for the affected patients, but for their families, community, and heath-care providers. Excellent palliative care should not be restricted exclusively to the dying. It is paramount that this paradigm be extended from the onset of a chronic illness throughout the disease trajectory until death. The goal needs to be on living with good symptom management, not just a "good death."
2. Canadian Palliative Care Association: Palliative Care: Towards a Consensus in Standardized Principles and Practice. Ottawa, Ontario, Canadian Palliative Care Association, 1995.
3. National Consensus Project: Clinical Practice Guidelines for Quality Palliative Care. Brooklyn, New York, 2004. www.nationalconsensusproject.org
4. Holman H: Chronic disease: The need for a new clinical education. JAMA 292(9):1057- 1059, 2004.