Palliative Care—The Challenge of Application

Author: Maria Cristina Dans MD
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NCCN has been a pioneer with regard to palliative care. In the 1990s, well before the American Board of Internal Medicine even recognized hospice and palliative medicine as a specialty in 2006, NCCN convened an interdisciplinary panel of experts to draft the first NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Palliative Care. First published in 2001, the NCCN Guidelines were and are designed as an evidence-based resource for oncologists and cancer care teams. Michael Levy, MD, PhD, the first chair of the Palliative Care Panel, described them at the time as the first NCCN Guidelines with death “as an expected outcome.”1

Despite the many advances in cancer treatments since then, many of our patients will unfortunately die of their cancer. The NCCN Guidelines for Palliative Care provide an opportunity for cancer care teams to promote the best possible quality of life (QOL) for their patients. An increasing body of evidence suggests that integrating palliative care into standard cancer care can not only improve symptom management and patient and family QOL, but also, in some cases, improve length of life and reduce cost of treatment. The evidence base has grown large enough that ASCO recently updated and upgraded its 2012 Provisional Clinical Opinion to a Guideline that proposes the integration of palliative care into standard cancer care “for all patients diagnosed with cancer.”2

Despite the growing recognition that the interdisciplinary team approach of palliative care can be extremely beneficial for patients with cancer and their families, barriers to implementation of the NCCN Guidelines for Palliative Care remain, even among NCCN Member Institutions. The 2015 NCCN Palliative Care Survey revealed that although most NCCN Member Institutions possessed both inpatient and outpatient palliative care services, 80% of the respondents reported that demand for these services outstripped capacity.3

NCCN Member Institutions also noted considerable disagreement on the potential benefits of palliative care, who should receive it, and when it should be started. Given that clinical trial data drive many treatment algorithms in cancer care, one of the suggestions for improving the integration of palliative care into standard oncology care has been to incorporate more palliative screening criteria, such as those included in the NCCN Guidelines, into prospective randomized clinical trials. Where and how patients access care and when they are referred to palliative services may also be points of intervention. Studies have shown that even though most patients who receive palliative care consultation as inpatients are admitted through the emergency department (ED), very little palliative care screening occurs in the ED.4 A recent prospective randomized clinical trial involving ED-initiated palliative care consultation for patients with advanced cancer suggested that this type of intervention might improve patient and caregiver QOL without shortening survival.5

Another approach to the question of how to better align oncologists' views with published guidelines, such as the NCCN Guidelines, may be to clarify primary and specialist palliative care. A study evaluating oncologist referral practices to subspecialty palliative care clinics suggests that increasing availability of palliative care services and positive referral experiences are important, but that these 2 factors are not sufficient by themselves because not all oncologists agree that palliative care is a valuable addition to standard oncology care.6 Some authors have promoted a distinction between primary and specialist palliative care as an opportunity to recognize the tremendous amount of basic palliative care that oncologists already provide their patients, in addition to acknowledging the fact that having specialist palliative care teams attend to all palliative care needs is not possible in most cases.7 Indeed, ASCO and the American Academy of Hospice and Palliative Medicine recently published a joint “guidance statement” delineating 9 domains essential to the delivery of high-quality palliative care in oncology practice.8

The answer to how to integrate palliative care into standard oncologic care will probably require a multifaceted approach, including clarifying palliative care interventions most important to oncologic care, showing further outcomes benefits from these interventions for patients with cancer, and raising the awareness of both oncologists and palliative care practitioners that ongoing collaboration is essential in the care of patients.

References

  • 1.

    Sussman ED. NCCN produces its first guidelines on palliative care. Oncology Times 2001;23:2526.

  • 2.

    Ferrell BR et al.. The integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. Available at http://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/2016-palliative-care-slides.pdf. Accessed November 28, 2016.

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  • 3.

    Calton BA, Alvarez-Perez A, Portman et al.. The current state of palliative care for patients cared for at leading US cancer centers: the 2015 NCCN Palliative Care Survey. J Natl Compr Canc Netw 2016;14:859866.

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    • Export Citation
  • 4.

    Grudzen CR, Hwang U, Cohen JA et al.. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med 2012;15:396399.

    • Search Google Scholar
    • Export Citation
  • 5.

    Grudzen CR, Richardson LD, Johnson PN et al.. Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial.” JAMA Oncol 2016;2:591598.

    • Search Google Scholar
    • Export Citation
  • 6.

    Schenker Y, Crowley-Matoka M, Dohan D et al.. Oncologist factors that influence referrals to subspecialty palliative care clinics.” J Oncol Pract 2014;10:e3744.

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    • Export Citation
  • 7.

    Quill TE, Abernathy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013;368:11731175.

  • 8.

    Bickel KE, McNivv K, Buss MK et al.. Defining high-quality palliative care in oncology practice: an American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement. J Oncol Pract 2016;12:e828838.

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Maria Cristina Dans, MD, is Director, Palliative Care Services at Barnes Jewish Hospital, Fellowship Director at Washington University School of Medicine Hospice & Palliative Medicine Fellowship, and Assistant Professor, Division of Hospitalist Medicine/Department of Internal Medicine at Washington University School of Medicine.

Dr. Dans graduated from Washington University School of Medicine in 1999. She completed a residency in Internal Medicine, followed by fellowships in Palliative Medicine and Critical Care Medicine at Stanford University in California. Dr. Dans is board-certified in Internal Medicine, Critical Care Medicine, and Hospice and Palliative Medicine.

Before working at Washington University and Barnes-Jewish Hospital, Dr. Dans worked as a surgical intensive care physician at Washington Hospital Center in Washington, DC. Dr. Dans still works in the ICU occasionally, but currently spends most of her time as the director of the Barnes-Jewish Hospital Palliative Care Service and as the Fellowship Director of the Washington University Hospice and Palliative Medicine Fellowship. She also serves as an associate editor for the American College of Surgeons ethics webpage, as a member of NCCN, and as Chair of NCCN Guidelines Panel for Palliative Care.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

  • 1.

    Sussman ED. NCCN produces its first guidelines on palliative care. Oncology Times 2001;23:2526.

  • 2.

    Ferrell BR et al.. The integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. Available at http://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/2016-palliative-care-slides.pdf. Accessed November 28, 2016.

    • Search Google Scholar
    • Export Citation
  • 3.

    Calton BA, Alvarez-Perez A, Portman et al.. The current state of palliative care for patients cared for at leading US cancer centers: the 2015 NCCN Palliative Care Survey. J Natl Compr Canc Netw 2016;14:859866.

    • Search Google Scholar
    • Export Citation
  • 4.

    Grudzen CR, Hwang U, Cohen JA et al.. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med 2012;15:396399.

    • Search Google Scholar
    • Export Citation
  • 5.

    Grudzen CR, Richardson LD, Johnson PN et al.. Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial.” JAMA Oncol 2016;2:591598.

    • Search Google Scholar
    • Export Citation
  • 6.

    Schenker Y, Crowley-Matoka M, Dohan D et al.. Oncologist factors that influence referrals to subspecialty palliative care clinics.” J Oncol Pract 2014;10:e3744.

    • Search Google Scholar
    • Export Citation
  • 7.

    Quill TE, Abernathy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013;368:11731175.

  • 8.

    Bickel KE, McNivv K, Buss MK et al.. Defining high-quality palliative care in oncology practice: an American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement. J Oncol Pract 2016;12:e828838.

    • Search Google Scholar
    • Export Citation
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