Palliative care (PC) is patient- and family-centered care for persons with life-threatening or debilitating illness that focuses on effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs, and cultures.1 The goal of PC is to prevent and relieve suffering, and to support the best possible quality of life for patients and their families, regardless of disease stage or the need for other therapies. Unlike hospice, PC can be delivered concurrently with life-prolonging care or as the main focus of care.
Now considered to be a core component of comprehensive cancer care,2 most cancer centers have a PC program in place.3 As these programs become more common, the next challenge is to ensure that patients who would benefit from these programs have access to them.4,5 Traditionally, referral to the PC program has been the prerogative of the oncologist. Under this rubric, referral is dependent on various factors, including the oncologist’s subjective judgment that referral is needed, their awareness of the program and what it can offer, and their willingness to refer.6,7 Each of these factors is a potential barrier to timely access.
In an effort to help overcome these barriers, the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Palliative Care recommend that all patients with cancer be screened for PC needs, and consultation or collaboration with a PC specialist is recommended when complex problems are identified (to view the most recent version of these guidelines, visit NCCN.org).1 Although in existence since 2003, the NCCN Guidelines have not been systematically evaluated for implementation or clinical impact.
The primary goal of this study was to assess the feasibility and sustainability of implementing the screening and referral components of the guidelines in patients admitted to the gastrointestinal oncology floor of the hospital (Memorial Hospital) of Memorial Sloan-Kettering Cancer Center (MSKCC), an NCCN-affiliated comprehensive cancer center (CCC) in New York City. Because the NCCN Guidelines for Palliative Care recommend that oncologists should screen and rescreen patients,1 the authors wanted to evaluate whether such a policy could be successfully introduced on a hospital floor and maintained for an extended period. The secondary goal was to determine the impact of screening on referrals to the hospital’s PC service, particularly to determine whether screening would result in more referrals, and what the patient characteristics and problems to be addressed would be when consults are triggered by a tool rather than requested by a clinician.
Hospitalized patients with gastrointestinal cancer are a relevant population in which to evaluate the NCCN Guidelines because gastrointestinal malignancies are responsible for approximately 15% to 20% of the 500,000 cancer deaths occurring annually in the United States.8 Because most chemotherapy and other cancer care are now provided on an outpatient basis, most medical admissions with gastrointestinal malignancies have advanced disease and are likely to have PC needs. The Gastrointestinal Oncology Service (GIOS) is the busiest solid tumor service at MSKCC, with more than 3000 new patients per year and more than 1200 admissions annually. To make the workload manageable, the GIOS inpatient service is divided into 2 teams (Team A and Team B). The decision to admit patients to either team is primarily based on equalizing the workload between them. Historically, approximately 10% of GIOS admissions are referred to MSKCC’s hospital PC service.
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