Integration of Palliative Care Into Comprehensive Cancer Care: Accountable Collaboration

In their article, Dennis et al call for timely integration of palliative care into standard oncology care and sustained collaboration between these two specialties, to provide comprehensive, individualized care for patients with advanced, incurable cancer and their families.[1] They state that this collaboration is needed because oncologists have difficulty identifying the palliative care needs of patients and families and delivering comprehensive care. The purpose of this collaboration is to provide appropriate, timely, comprehensive, and cost-effective care that addresses symptom management, transitioning from disease-focused care to palliative care, discussing goals of care and advance care planning, community care, and psychosocial support for patients and their families. This call is a commendation to palliative care, an admonishment to oncology, and a challenge to the entire healthcare delivery system. For this collaboration to be successful, palliative care, oncology, and the healthcare delivery system must each be held accountable.

The National Quality Forum defines palliative care as both a philosophy of care and an organized, highly structured system for delivering care. It is an approach that not only improves the quality of life of patients facing life-threatening illness through prevention, assessment, and treatment of pain and other physical, psychosocial, and spiritual problems, but also addresses the quality of life for patients' families. Palliative care can be delivered concurrently with life-prolonging care or as the main focus of care. Ideally, palliative care begins at the time of diagnosis of a life-threatening or debilitating condition and continues through cure, or until the patient's death, and into the family's bereavement period.[2] Two major barriers to timely collaboration between oncology and palliative care are the lack of a precise indication of when a patient should be referred to a palliative care specialist/program and the lack of public demand for such referral. Because palliative care is not focused upon one organ system or one disease type, the indications for palliative care consultations are more diffuse than those for consultations from cardiology, nephrology, infectious diseases, or oncology. Because of this diffuseness, recommendations for palliative care consultation may be viewed by the oncologist as an implied insult. Patients and families might perceive that a palliative care referral means that they have failed. There remains a gap between patient recognition that the mortality of being human is 100% and a patient's demand for state-of-the-art palliative care before that death. Without developing a consensus on the appropriate time for palliative care referral and closing the gap between reality and false hope, many patients will die without receiving the benefits of palliative care or will be referred so late in their disease course that those benefits will be constrained.

The American Society of Clinical Oncology (ASCO) stated in 1998 that it is the oncologist's responsibility to care for patients in a continuum that extends from the moment of diagnosis throughout the course of the illness.[3] This care should include appropriate anti-cancer treatment, symptom control, psychosocial support, and optimal end-of-life care. ASCO proposed remedies to barriers to the provision of optimal end-of-life care; these barriers include clinical oncology issues, lack of availability of palliative care services, fragmentation of care, administrative and fiscal limitations, educational deficiencies, and a paucity of clinical research evidence. An ASCO task force evaluated the results of a decade of these proposed remedies and found that changes in current policy, drug availability, and education were still needed to achieve integration of palliative care throughout the experience of cancer.[4] Despite strides made over the past decade, the task force felt that the need for palliative cancer care was greater than ever. Earlier this year, ASCO published a statement advocating an individualized approach to discussing and providing disease-directed and supportive care options for patients with advanced cancer.[5] This approach was aimed at expanding personalized cancer care based upon the biologic features of the patient's disease, to care tailored to the diverse physical, psychological, social, and spiritual consequences of cancer for each individual patient. ASCO saw this statement as a clarion call for oncologists as medical practitioners, and for the oncology profession in general, to take the lead in curtailing use of ineffective anti-cancer therapy and ensuring provision of palliative care to all patients with advanced cancer. It is troubling that, despite all of these efforts by ASCO, Dennis et al still found that oncology treatment programs have difficulty assessing and managing the many domains of care required by patients with incurable cancer. There is much to do to actualize ASCO's vision of individualized cancer care. Oncologists must be held accountable for effective palliative care for their patients, whether they provide it directly or in collaboration with palliative care specialists/programs.

Until palliative care is more fully integrated into the training and standards of oncology care, enhanced collaboration between oncology and specialized palliative care is essential. Dennis et al recognize that more research is needed to develop the ideal model of this collaboration. The National Comprehensive Cancer Network (NCCN) developed its first Palliative Care Guideline in 2001 as a consensus document that incorporated available evidence.[6] This guideline has been updated annually by its panel based upon review of the literature and comments from member institutions.[7] It is meant to guide decision-making by the primary oncology team of physicians, nurses, social workers, other mental health workers, and chaplains. The guideline recommends routine screening for palliative care needs, full assessment of identified needs, provision of interventions to meet these needs, ongoing reassessment and treatment modification, and after-death interventions for family and caregivers and the healthcare team. Treatment interventions are recommended in clusters that take into account whether the patient's survival is expected to be measured in years, months to a year, weeks to months, days to weeks, or hours to days. The aim of this guideline is for oncologists to integrate palliative care into their general oncology care. Early consultation/collaboration with a palliative care specialist/team should be considered to help improve both quality of life and survival. The confusion of patients regarding prognosis and goals of care mentioned by Dennis et al must be addressed first by the oncologist. The oncologist must clarify the meaning of terms such as remission, response, stable disease, survival, and prognosis, and should connect these terms to the patient's goals and expectations. Palliative care specialists must be accountable for being up-to-date with the oncologist's treatment plan and the patient's expectations. The best-intended palliative care intervention can be rejected if the oncologist feels that it will interfere with the oncology treatment plan or if the patient feels that the palliative care assessment is discordant with his or her current expectations.

Ideally, oncologists should introduce palliative care early in their encounter with each patient, to normalize the provision of palliative care as part of comprehensive cancer care. The primary oncology team should initiate palliative care to help the patient and family cope with cancer and its therapy. When the oncology team needs to collaborate with a palliative care specialist/team, the rationale for that collaboration must be explained and endorsed by the oncologist, to prevent any sense of desertion or duplication of services. Effective collaboration will require each specialist to communicate regularly. As the patient's disease progresses, palliative care should be intensified. This transition should be led by the oncologist with the support of the palliative care specialist. When palliative care becomes the sole focus of the patient's care, it is important for the oncologist to remain engaged to prevent a sense of abandonment and to promote closure.

The final challenge to sustained collaboration between oncology care and palliative care is that of holding the healthcare delivery system accountable for adequate reimbursement for interdisciplinary care needed by cancer patients and their families. The community care and psychosocial support for the patient and family that Dennis et al recommend should be covered as essential components of standard cancer care. Special oncology and palliative home care teams are working with oncologists to provide home care to patients who are not eligible for routine home care but are not yet ready or not yet appropriate candidates for hospice home care. This community oncology care needs a more stable stream of reimbursement. The type of psychosocial support described by Dennis et al should be met first by standard psycho-oncology services.[8] Such cognitive services have been undervalued and inadequately reimbursed for decades, despite efforts to bring them to parity. Universal access to skilled psycho-oncology services is a challenge to palliative care programs, let alone to oncology programs. These deficiencies in the current healthcare delivery system should be corrected because they provide better quality of life, not because they might reduce costly readmissions or overuse of other expensive services. The healthcare delivery system must also provide funds to train more palliative care specialists and to identify the ideal model of oncology and palliative care collaboration through outcomes research.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. Dennis K, Librach SL, Chow E. Palliative cancer care and oncology: integration leads to better care. Oncology (Williston Park). 2011; ( ): ( - ).

2. National Quality Forum. A National Framework and Preferred Practices for Palliative and Hospice Care Quality. 2006; National Quality Forum, Washington, DC. Available at http://www.qualityforum.org/publications/reports/palliative.asp. Accessed November 1, 2011.

3. American Society of Clinical Oncology: Cancer care during the last phase of life. J Clin Oncol. 1998;16:1986-96.

4. Ferris FD, Bruera E, Cherny N, et al. Palliative cancer care a decade later: accomplishments, the need, next steps–from the American Society of Clinical Oncology. J Clin Oncol. 2009;27:3052-8.

5. 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;29:755-60.

6. Levy MH, Carducci MA, Weinstein SM. The NCCN Palliative Care Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 1:394-420, 2003.

7. Levy MH, Block S, Weinstein SM. The NCCN Palliative Care Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2009;7:436-73. Available at http://www.nccn.org. Accessed November 1, 2011.

8. Holland JC, Andersen B, Brietbart WS, et al. The NCCN Distress Clinical Practice Guideline in Oncology. J Natl Compr Canc Netw. 2010;8:448-85. Available at http://www.nccn.org. Accessed November 1, 2011.