In its latest push to increase the use of palliative care for patients with advanced cancer, the American Society of Clinical Oncology has issued a “provisional clinical opinion” (PCO) recommending that all patients with metastatic non-small-cell lung cancer be offered palliative care along with standard treatment, beginning at diagnosis.
The guidance, now available online ahead of print in the Journal of Clinical Oncology (doi: 10.1200/JCO.2011.38.5161) seeks to change the way oncologists treat patients with advanced disease. Currently, many patients suffer because their physicians do not understand two important facts about palliative medicine.
“One important message is that palliative care should not be equated with end-of-life care,” said Jamie Von Roenn, MD, one of the coauthors of the PCO and a professor at Northwestern University's Feinberg School of Medicine who practices at Robert H. Lurie Comprehensive Cancer Center. “Symptoms from cancer—curable or not—and its treatment can be significant, and we can have a huge positive impact on patients by addressing their symptoms.”
The second point: Many oncologists do not realize their shortcomings in alleviating their patients' suffering. “Pain management is a perfect example,” she said. “Oncologists report they know how to treat cancer pain, but the number of patients with severe inadequately treated cancer pain remains significant.”
The PCO was triggered by research findings that patients with advanced NSCLC who concurrently receive palliative care and standard treatment had improved quality of life and longer survival than patients who received standard care only (Temel J et al: NEJM 2010;363:733-742).
Among the benefits of concurrent treatment: Less depression among patients and their family members, fewer hospitalizations and resuscitations near the end of life; less use of intravenous chemotherapy in the last six days of life; and increased use of hospice services.
“What was very striking was that people lived 2.7 months longer,” said another coauthor, Thomas J. Smith, MD, Professor of Oncology and Director and the Harry J. Duffey Family Professor of Palliative Medicine at Johns Hopkins Medical Institutions. “If this were a drug, we would be down at the FDA headquarters, trying to occupy it.”
Although that research with NSCLC patients is the basis for the PCO, the document states that concurrent palliative care should be considered for other patients as well. Von Roenn noted that a review of the literature demonstrates that adding palliative care to antitumor therapy does not cause harm, and that aggressively managing patient symptoms and concerns provides positive benefits for patients and their families. “It would be reasonable to apply it to any patient with either a high symptom burden or metastatic disease.”
How Oncologists Should Respond
Smith said oncologists do not use palliative care resources to full advantage because their training emphasizes curative treatment and measures success by length of survival, and in issuing the PCO, ASCO wants oncologists to change the way their patients with advanced diseases are cared for.
“Sixty percent of us don't like to have any do-not-resuscitate, hospice, or advanced medical directive discussions until there's no chemo left to give,” he said.
But by delaying frank discussions with their patients who are likely to die within several months, oncologists are denying those patients the opportunity to make important decisions about how to spend their time. “That typically gives people just about two weeks—maybe four at the most—before they have to change their whole mindset from fighting this disease to, ‘I'm actually going to die from this, and there are a lot of things I have left to do. I haven't changed my finances, I haven't made spiritual peace, I haven't made family peace, I haven't visited my brother in Los Angeles, etc. We are hoping that, with the emphasis on palliative care, oncologists like me can learn to bring up these issues sooner.”
He and Von Roenn offer the following suggestions on how oncologists can comply with the spirit of the new PCO:
- Test yourself. ASCO's Quality Oncology Performance Initiative (QOPI) recently added hospice and palliative care measures (see box.) Oncology practices that participate in QOPI can benchmark their performance against their peers. Another idea is to give each patient a one-page questionnaire asking patients about their symptoms: “On a 0 to 10 scale, patients can mark whether they have it or they don't have it, and how severe it is. See if the results that you get are what you have in your chart. Are you really addressing all the symptoms?”
- Get to know the hospice resources. Although oncologists have close working relationships with radiation therapists and surgeons, many do not know the palliative care and hospice providers in their community. “This is really important, because a third of all cancer patients go into hospice with less than seven days left to live. That means the hospice team is really managing the acute death,” said Smith. He encourages oncologists to meet with hospice providers, learn about their palliative care services, and develop a working relationship that is as close as they have with others in their referral network. Ask them about their organization's average length of stay in hospice, and look for providers that have 30 days or longer.
- Connect patients with hospice resources before death is imminent. “One of the simplest things we're asking oncologists to do is to have a hospice information visit when people realistically have three to six months left to live. That gives the hospice team time to get to know the patient, get to know the family, plan for social work help, plan for chaplaincy help.
“That step helps the oncologist when the time for transition to full hospice care comes. I can say, ‘Remember when we first met and we talked about…that there would be a time when chemo wouldn't have the ability to make your cancer go away? Well, that time is now, and I really want to call Bob, the hospice nurse that you met, and get you enrolled in hospice. I'll still be your doctor, you can still have contact with the nurses here. You're not losing us, but I need this team to help me in this phase of your illness.’”
- Stay in touch with hospice patients. Oncologists may be reluctant to refer patients to hospice care because they do not want to end the relationship. Dr. Smith recommends that oncologists make a point to call each of their hospice patients on a regular basis. “When I'm in clinic on Thursday morning and I see my list of hospice patients, there's a little yellow box there that says, “Call Mrs. So-and-so,” he said. “That helps me stay connected, and I think it really helps our patients stay connected with us and know that we care.”
Key QOPI Palliative Care Measures
- Was the patient assessed for pain when initially seen and at his/her most recent visits?
- Was the patient's pain quantified?
- If the patient experienced moderate or severe pain, is there evidence in the chart that there was action to address that pain?
- If a patient was prescribed a narcotic, was he/she counseled about the risk of constipation and was the effectiveness of the narcotic assessed during the patient's next visit?
- Was the patient's emotional well-being status assessed and if a problem was noted, is there evidence in the chart that there was action to address that problem?
- Was the patient given medication to manage nausea when receiving certain chemotherapy agents?
- Was the patient enrolled in hospice in a timely manner?
- Was the patient offered comprehensive palliative care services or referred to a palliative care specialist before death?
- Did the patient receive chemotherapy in the last 14 days before death? (overuse measure)
This description of some of the palliative care measures included in QOPI was provided by ASCO. The full list of the 89 QOPI Measures (current as of this spring, and available as a five-page pdf document) is on the QOPI website at qopi.asco.org/Documents/QOPISpring2012MeasuresSummary_000.pdf
Joint Commission Awards First Advanced Certifications for Palliative Care
Regions Hospital in St. Paul, MN; Strong Memorial Hospital in Rochester, NY; Mount Sinai Medical Center in New York City; St. Joseph Mercy Oakland in Pontiac, MI; and The Connecticut Hospice in Branford, CT have become the first hospitals across the country to receive Advanced Certification for Palliative Care from The Joint Commission.
“Seriously ill patients will benefit from the decision by these five leading hospitals to follow national standards and evidence-based guidelines that emphasize the need for expert caregivers to work together as teams with patients and their families,” the Joint Commission's Executive Director for Advanced Certification for Palliative Care, Michele Sacco, said in a news release.
The Joint Commission Advanced Palliative Care Certification standards emphasize:
- A formal, organized palliative care program led by an interdisciplinary team whose members possess the requisite expertise in palliative care;
- Leadership endorsement and support of the program's goals for providing care, treatment, and services;
- A special focus on patient and family engagement;
- Processes that support the coordination of care and communication among all care settings and providers; and
- The use of evidence-based national guidelines or expert consensus to guide patient care.
Further information about the program is available at http://www.jointcommission.org/facts_about_palliative_care
Podcast: Tom Smith on Standard + Palliative Care
Listen on the iPad edition of this issue as Dr. Smith, Professor of Oncology and Director of Palliative Care at Johns Hopkins, elaborates on what he said in this article.
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