A partnership forged to improve palliative care in oncology was announced in March by the American Society of Clinical Oncology and the American Academy of Hospice and Palliative Medicine (AAHPM). The aim, the organizations said, is to “harness technology to foster improved palliative care in oncology” and “help oncologists support cancer patients with evidence-based palliative care interventions.”
“This partnership will help get the latest palliative care evidence directly into the hands of oncologists so that palliative care can be provided as early as possible,” ASCO President Sandra Swain, MD, said in a statement.
On the same day that the three-year initiative funded by the Agency for Health Care Research Quality (AHCRQ) was announced (March 6), a Perspective article by the AAHPM's Immediate Past President and 2013 President was published in the New England Journal of Medicine (2013;368:1173-1175). Titled “Generalist plus Specialist Palliative Care—Creating a More Sustainable Model,” the article by Timothy E. Quill, MD, and Amy P. Abernethy, MD, recommended developing a care model that distinguishes between primary palliative care skills available to all clinicians and specialist palliative care skills for managing more complex cases.
The two medical societies' joint initiative will support delivery of high-quality palliative care in oncology addressing the complex care needs of patients with advanced cancer, including relief or prevention of symptoms. The aim is to recruit 20 oncology practices from around the country to participate in the pilot project.
As noted in interviews for this article, the project will use ASCO's Quality Oncology Practice Initiative (QOPI) to move palliative care more into the mainstream of oncology practice with a smoother handover between oncologists and palliative care specialists providing better, earlier, and more widespread care for cancer patients.
Research has shown that palliative care benefits patients with advanced cancer, and that those who receive the intervention earlier rather than later have a better quality of life, less depression, and in some cases even live longer than those receiving routine care.
But the general acceptance of palliative care has often been plagued by misunderstandings among medical professionals and the public alike about what the intervention is and when it should take place. Many continue to confuse palliative care with hospice care and believe it is appropriate only when delivered at the end of life.
I spoke with both Quill and Abernethy by telephone a few days before AAHPM's Annual Assembly (March 13-16 in New Orleans), where Abernathy succeeded Quill as President.
A general internist and board-certified palliative care consultant, Quill is Professor of Medicine, Psychiatry, and Medical Humanities at the University of Rochester School of Medicine and Dentistry, and Director of the Center for Ethics, Humanities and Palliative Care.
He said that until this joint project there had been smaller initiatives but that the partnership would allow a more systematic look at what training in hospice and palliative care can be and how to make it more generally available to physicians and produce specific outcomes.
Oncologists and other medical specialists need to know more about primary palliative care, Quill said, noting that studies show there will not be enough palliative care specialists to serve the needs of all patients.
“It's a breakthrough idea to move primary palliative care back to those already providing care. The old model is to add another layer of expertise on sick people and deliver palliative care to sick people by specialists,” he said, adding that the new model encourages relationships between clinicians to be more continuous rather than fragmented. “Palliative care is a piece of good care for sick people, and reserving it for the end of life is crazy.”
While Quill's perspective includes having medical specialists from oncology, cardiology, critical care, geriatrics, primary care, surgery, and other fields learn to deliver basic palliative care, Abernethy—a medical oncologist specializing in melanoma as well as health services research and delivery in patient-centered cancer care including pain, symptom management, and palliative care—is focused on oncology. Ultimately, though, she wants to use the ASCO-AAHPM project to create models for others specialties as well.
She is Director of both the Center for Learning Health Care and the Duke Cancer Care Research Program, and Associate Professor of Medicine with Tenure in the Division of Medical Oncology at Duke University School of Medicine.
In addition to being the new AAHPM President, she serves in a variety of capacities for numerous organizations, affording her the perspective and opportunities to move the palliative care initiative ahead within them in various ways. She noted that in the late 1990s, she wanted to go to Australia to study palliative care but instead had to say she'd be studying “cancer pain,” because palliative care was still not well understood in the United States at the time.
She also explained that the American College of Surgeons' Commission on Cancer's mandate that distress screening be part of cancer care for accreditation has opened the door for other psychosocial services.
Abernethy is principal investigator for the ASCO-AAHPM project, which, according to the announcement, will create a virtual learning collaborative using web-based technology to disseminate evidence-based palliative care approaches in oncology—including customized learning modules, social networking, and an evidence-based toolbox offering resources to translate research into practice.
The 20 oncology practices in the pilot program will report palliative care quality data through QOPI, sharing best practices and resources. The program will also:
- Evaluate oncologists' perceptions of the virtual learning;
- Assess the impact on performance related to primary palliative care;
- Provide refinements to both the platform and toolbox; and
- Develop a palliative care toolbox for all ASCO members.
Abernethy said the AHCRQ three-year grant is for a “relatively small” $300,000, meaning that the project will have to be creative to cover all costs. She said AHCRQ grants, although difficult to get and not very substantial, can be wide-reaching in terms of health care delivery, and so she used her various organizational affiliations to broker a proposal that would use both ASCO's and AAHPM's respective strengths.
“ASCO's contribution is really enormous,” she said. “ASCO has the technology platform and machinery with QOPI that can function as both a monitoring and quality improvement program, as well as the ability for distribution [among its large membership]. And AAHPM has the content and know-how to work with ASCO to bring teaching primary care to oncologists and create a model that can also be used for other medical specialists.”
‘Skill Sets’ for Primary vs. Specialist Palliative Care
The NEJM article, now online ahead of print, broke down the various representative skill sets for primary and specialty palliative care, noting that primary palliative care includes:
- Basic management of pain and symptoms;
- Basic management of depression and anxiety; and
- Basic discussions about prognosis, goals of treatment, suffering, and code status.
Specialty palliative care, on the other hand, Quill and Abernethy say, includes:
- Management of refractory pain or other symptoms;
- Management of more complex depression, anxiety, grief, and existential distress;
- Assistance with conflict resolution regarding goals or methods of treatment within families, between staff and families, and among treatment teams; and
- Assistance in addressing cases of near futility.