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Palliative Care Pushing into Outpatient Settings

Butcher, Lola

doi: 10.1097/01.COT.0000425686.80125.66


Buoyed by research that shows early palliative care for cancer patients with advanced disease can improve the quality of life and increase survival time, the nonprofit Center to Advance Palliative Care has launched a new initiative to improve palliative care in cancer care clinics and other outpatient settings.

Called IPAL-OP (Improving Palliative Care—Outpatient), it brings together tools, including needs assessment worksheets, case studies, and a “getting started” guide, to help integrate palliative care into medical clinics and home care settings.

The project is designed to help oncologists meet the new standards of care that have emerged this year, said Michael W. Rabow, MD, Director of the Symptom Management Service at Helen Diller Family Comprehensive Cancer Center and Professor of Clinical Medicine at the University of California, San Francisco.

The provision of palliative care services either on-site or by referral was added to the Commission on Cancer's new Cancer Program Standards, which went into effect in January 2012.

The American Society of Clinical Oncology issued a Provisional clinical opinion that palliative care services should be integrated into standard oncology practice at the time a patient is diagnosed with metastatic or advanced cancer (OT, 3/25/12).

“For oncologists who are facing [ASCO's] recommendation and guideline, as well as the regulatory requirements from the Commission on Cancer, IPAL-OP provides the detailed specifics necessary to develop palliative care services fitted to the oncologists' practice environment and patient population,” said Rabow, a member of the project's advisory board.

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The IPAL Project

IPAL-OP is the third initiative of the IPAL Project. In 2010, the project launched “Improving Palliative Care in the ICU” and, a year later, introduced “Improving Palliative Care in Emergency Medicine.”

As it turned its attention to outpatient care, the Center convened an advisory board from various disciplines, including Carol Luhrs, MD, Section Chief of Hematology/Oncology at the Veterans Administration-New York Harbor Healthcare System in Brooklyn.

An oncologist—David E. Weissman, MD, founder of the Medical College of Wisconsin Palliative Care Center and Director of the Medical School Palliative Care Education Project—was a co-director of IPAL-OP. “Not only oncology, but everyone else, has been clamoring for more resources in the area of outpatient care,” he said. “Two other big areas of interest are cardiology and home-based programs—i.e., how do we get palliative care services out to the home?”

IPAL-OP defines “outpatient” to include any care settings outside the hospital, so it will eventually include resources for clinic-based practices, home-based care providers, and institutions such as skilled nursing and assisted living facilities. A profile of an oncology outpatient practice that integrates palliative care will be posted to the website in early 2013.

Other improvement tools available on the site include pain cards, templates for making referrals, job descriptions for palliative care staff members, patient satisfaction surveys, communication aids, and program brochures.

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Evidence Drives Interest

Oncologists' interest in palliative care is being spurred by a study that compared outcomes for non-small-cell lung cancer patients who received concurrent oncologic care and palliative care with those of patients who received only cancer treatment. The study (NEJM 2010;363:733-742), conducted by Jennifer S. Temel, MD, and her colleagues at Massachusetts General Hospital, included 151 patients who were randomly assigned to one of the groups.



Patients who received concurrent care reported a better quality of life and less depression than those in the comparison group. They more frequently had documented do-not-resuscitate orders, used less chemotherapy near the end-of-life, and had longer times on hospice care. What's more: Despite the fact that fewer patients in the early palliative care group received aggressive medical interventions at the end of life, their median survival was longer—11.6 vs. 8.9 months—than those in the control group.

That study is the bellwether that is pushing palliative care forward in oncology, Rabow said. “Nowhere else in the world of outpatient palliative care do we have better data and real-world data to suggest that this actually makes sense, both clinically and in terms of health care utilization.”

That study prompted ASCO to issue the Provisional Clinical Opinion, but it will take a while to change practice patterns, Weissman said. “The prevailing ethos in the oncology community historically has been that you don't call palliative care until a patient is on death's doorstep.

“I see this as a generational issue. It may take a whole new generation of doctors populating the field who have been trained in palliative care during their oncology fellowship who understand these issues, for us to see a major transformation.”

Rabow said he thinks oncologists will value palliative care as they learn more about it. “The key is to understand that the provision of outpatient palliative care is not an either/or situation,” he said. “It's really meant to be provided simultaneously with oncologic care.”

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Status of Palliative Care

The new Commission on Cancer program standard says that, to be an accredited cancer center, a provider must make outpatient palliative care services available either on-site or by referral to another location. “They have made a really important regulatory statement, but it's totally unclear at this point how most cancer centers are going to actually meet that requirement because there's so much need that's unmet now,” Rabow said.

The percentage of cancer care providers who currently provide palliative care services is not known, he noted. In California, where he practices, he estimates that about 20 percent of oncology providers offer some palliative care services to their patients.

“We do know a few things from some research, which suggests that probably outside of comprehensive cancer centers, it's relatively rare to have outpatient palliative care services,” he said. “Our best guess is that only a small minority of patients with palliative care needs in the outpatient setting currently have access.”

The demand for palliative care services will have to be met by an increase in generalist or “primary” palliative care, which can be provided by physicians, mid-level providers, and nurses who have received training in basic palliative medicine, working in conjunction with palliative care specialists.

“We are seeing more and more integration by using collaborative relationships between palliative care specialists and oncology outpatient practices,” Weissman said. “The outpatient community oncologists and academic oncologists have come to realize that palliative care specialists in their practice setting can be a great enhancement to their practice, can make their life more efficient, and improve outcomes. So lots of good things can happen from that relationship.”

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David Weissman, MD

David Weissman, MD

PODCAST: Are you providing adequate palliative care?

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© 2012 Lippincott Williams & Wilkins, Inc.
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