“We physicians are trained to do things a certain way, and whatever we were not trained in, we don't do. So an oncologist who's basically trained to give chemotherapy for cancer and doesn't understand that other modalities, including palliative care, are really important to the health and well-being of the patient, won't deploy those resources because it wasn't in their training.”
Don't Confuse Palliative Care & Hospice
Dr. Meier did, though, have a strong objection to one aspect of the ASCO statement, saying that it should not have included discussions about palliative care and end-of-life in the same document.
Hospice care is for patients who are clearly dying, she said, and not for people living with a serious chronic illness who are not eligible for hospice because they're still benefiting from life-prolonging treatment.
“That's where the gap is, and I think that to the extent that this report unfortunately linked palliative care to end-of-life care, many people will be afraid to ask for it,” she said. “And to the extent that they think you're giving them palliative care because you're preparing them for death, they don't want any part of it.”
She said it is a very confusing message and it might have been addressed somewhat differently. Nonetheless, she said, the overarching message to the members of ASCO is a very important step forward—that “oncologists in practice can no longer afford to think that palliative care is somebody else's job.”
Asked about this critique, Dr. Peppercorn said some people have focused on the fact that one of the statement's recommendations is to ensure a transition to palliative care once evidence-based options have been exhausted.
“Overall, I agree that the issue is less about end-of-life care and more about how we treat patients and provide them the full range of evidence-based options, including palliative care and disease-directed therapy, throughout their illness,” he said.
“The statement itself does not focus on hospice or end-of-life care, but it does focus on the need to step out of the mode of only considering one line of disease-directed therapy after another, and to ask ourselves and our patients: what are the patient's goals; what are the options; are we adequately addressing quality of life; and how should we balance disease-directed and palliative care moving forward?”
Dr. Peppercorn said he understands the concerns raised by the palliative care community about associating palliative care with end-of-life care, “but they miss some of the point—that the statement's target audience includes oncologists who are not using an individualized approach and are likely never discussing these issues with patients, or not until very late in the course of illness.”
Make Time for Discussion
The Chief of the Pain and Pal-liative Care Service at Memorial Sloan-Kettering Cancer Center, Paul A. Glare, MD, strongly endorsed the statement.
But he added that ASCO should not minimize the problem of making time for these discussions with patients.
Fitting time into an oncologist's schedule to discuss palliative care is no small matter, Dr. Glare said.
“It does take a lot of time, it's challenging, and it's very draining,” he said.
Although time available for office visits is limited, Dr. Glare said many patients with advanced cancer are fragile and some travel long distances, making it difficult for them to return to the cancer center to discuss possible palliative options.
“Time must be found for them while they're here,” he said, noting that Memorial Sloan-Kettering has a palliative care clinic in midtown Manhattan (at 53rd Street) open six days a week, where physicians can get help about informing patients about palliative care options.
Dr. Glare agreed with Dr. Meier on the importance of separating palliative care from hospice.
“Palliative care is for people who've got advanced cancer that's probably not curable and they're going to die from it,” Dr. Glare said. “And while they're having their disease-controlling treatment, even though their disease can't be cured, hopefully it can be controlled, and at the same time they want to have their symptoms controlled.”
That said, he does believe that for some selected patients it is appropriate to discuss palliative care and hospice together, while for others it is important to explain that palliative care is not the same as hospice.
Dr. Glare also thought it important to distinguish between palliative care that an oncologist ought to be able to provide, and what is needed in the more complicated, time-consuming cases when a palliative care specialist can help the oncologist with symptom control, psychosocial issues, and family support.
And if the patient is dying, the specialist can help the transitioning to hospice.
“It's an important part of palliative care to recognize when the time has come and assist with the transition” to hospice care, he said.
The ASCO Statement, “Toward Individualized Care for Patients with Advanced Cancer,” was published online in JCO on January 24 (doi: 10.1200/JCO.2010.33.1744). The 24-page patient brochure, “Advanced Cancer Care Planning: What Patients and Families Need to Know about Their Choices When Facing Serious Illness,” is available at http://www.cancer.net/patient/Coping/Advanced+Cancer+Care+Planning
Resources & Training
For oncologists in practice who want additional training and skill in palliative medicine, Dr. Diane Meier recommended the Board Review course given by the American Academy of Hospice and Palliative Medicine (AAHPM).
Even a physician not taking the Boards can get some immersion content, she said.
Also, Harvard University Medical School gives an annual conference on clinical aspects of palliative medicine for non-palliative medicine physicians.
And on-line courses are available through EPEC.net (Education and Palliative and End-of-Life Care). Both oncologists and their patients can find palliative expertise in their neighborhood through getpalliativecare.org, a provider directory, Dr. Meier said.© 2011 Lippincott Williams & Wilkins, Inc.
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