Early Integration of Palliative and Supportive Care in the Cancer Continuum: Challenges and Opportunities

Author(s):  
Mellar P. Davis ◽  
Eduardo Bruera ◽  
Daniel Morganstern

Palliative care has become synonymously associated with hospice care in the minds of patients and physicians. Supportive care is a more acceptable term and leads to earlier referral. Miscommunication and a “collusion of hope” centered on cancer treatment is detrimental to care at the end of life and results in complicated bereavement. Patients, despite being told prognosis, may not comprehend the news even if delivered in an empathetic manner. There are resource and policy barriers to palliative care. However, integration of palliative care early in the management of advanced cancer has demonstrated multiple benefits without reducing survival.

Author(s):  
Ellis C. Dillon ◽  
Amy Meehan ◽  
Catherine Nasrallah ◽  
Steve Lai ◽  
Natalia Colocci ◽  
...  

Background: Individuals with advanced cancer and their families have negative end-of-life experiences when the care they receive is not aligned with their values and preferences. Objective: To obtain in-depth information on how patients with advanced cancer and the oncology and palliative care (PC) clinicians who care for them discuss goals of care (GoC). Design: The research team conducted in-depth interviews and qualitative data analysis using open coding to identify how perspectives on GoC discussions vary by stage of illness, and experience with PC teams. Setting/Subjects: Twenty-five patients and 25 oncology and PC team members in a large multi-specialty group in Northern California. Results: At the time of diagnosis participants described having establishing GoC conversations about understanding the goal of treatment (e.g. to extend life), and prognosis (“How much time do I have?”). Patients whose disease progressed or pain/symptoms increased reported changing GoC conversations about stopping treatment, introducing hospice care, prognostic awareness, quality of life, advance care planning, and end-of-life planning. Participants believed in the fluidity of prognosis and preferences for prognostic communication varied. Patients appreciated how PC teams facilitated changing GoC conversations. Timing was challenging; some patients desired earlier conversations and PC involvement, others wanted to wait until things were “going downhill.” Conclusion: Patients and clinical teams acknowledged the complexity and importance of GoC conversations, and that PC teams enhanced conversations. The frequency, quality, and content of GoC conversations were shaped by patient receptivity, stage of illness, clinician attitudes and predispositions toward PC, and early integration of PC.


2021 ◽  
pp. 35-43
Author(s):  
Russell K. Portenoy

Definitional inconsistencies and confusion about core principles and practices have been part of the history of palliative care for more than five decades. The term ‘palliative care’ was first used to describe clinical services that had a singular focus on end of life care, particularly in the context of cancer; the ‘good death’ was its definitional touchstone. Modern use of the term ‘hospice’ predated this label and described services with the same intent, and ‘supportive care’, a term that emerged decades later, referenced elements that were comparable. Over time, the use of these labels evolved, and although global consensus has not yet been achieved, the development of palliative care as a clinical discipline has promoted greater agreement. Specialists increasingly favour the use of ‘palliative care’ to depict a multiprofessional model of care appropriate for all populations with potentially life-limiting chronic illnesses, the goal of which is to enhance the potential for a satisfactory quality of life and end of life experience by preventing or managing the suffering and illness burden of the patient and family. Around the world, specialists use both ‘palliative care’ and ‘hospice’ to describe programmes that advance the objectives of palliative care; ‘hospice’ is usually preferred when programmes serve those with advanced illness and short prognosis in a home-like environment. ‘Supportive care’ is generally applied to a parallel oncology-based model with a strong focus on problems related to cancer treatment. As specialist palliative care programmes are continuing to emerge globally, expansion of the model of care is occurring through early integration approaches that include the efforts of non-specialists. This chapter discusses the evolving perspectives on the definitions applied to palliative care and related terms, and the core principles and practices that have supported its global development.


2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 50-50
Author(s):  
Leslie J Blackhall ◽  
Paul W Read ◽  
George Stukenborg ◽  
Margaret Barclay ◽  
Patrick M Dillon ◽  
...  

50 Background: Recent studies suggest that early integration of palliative care services into the care of patients with advanced cancer can improve end of life care. Unfortunately, there are insufficient resources for all advanced cancer to see palliative care from time of diagnosis. This 2012 CMS innovation award is attempting to improve identification of cancer patients in need of palliative care. Methods: In Year 1 of this award, increased staffing was added to existing palliative care resources to improve access. Patients were referred at discretion of their oncologist. A control group consisting of patients with similar diagnoses not referred to palliative care was identified including those without any contact with palliative care, and those who only saw palliative care in the hospitalization prior to death. Data regarding hospitalization in the last month of life, and hospice utilization was obtained. Results: Median time between referral to palliative care clinic and death was 72.5 days (mean 112). See table below. Conclusions: These data suggest patients referred to palliative care clinic within 3 months of death had benefits similar referral at time of diagnosis. However, many patients were never referred or referred only at the very end of life. The next phases of this award will utilize patient-reported outcome data to better identify those who need palliative care. Although most palliative care services are hospital-based, in this study, in-patient consultation only was too late to provide much benefit for these patients. Re-focusing scarce palliative care resources to the out-patient setting may have greater impact on patient care. [Table: see text]


2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 67-67
Author(s):  
Adi Joseph Klil-Drori ◽  
Karine Silva ◽  
Tracy Regimbald ◽  
Sarit E. Assouline

67 Background: ASCO endorses early integration of palliative care in the treatment of patients with advanced cancers and encourages patient education with regards to prognosis and participation in medical decision making. We implemented a uniform process of discussing end of life and advance directives (AD) early in the course of experimental cancer treatment and assessed whether this process is aligned with our patients' perspectives. Methods: This was a pilot study in a research unit conducting early-phase trials for patients with no remaining standard of care. Accrual goal was 15 patients in four months. We identified patients with advanced malignancies who were screened for cancer trials and approached their physicians with a request to fill out an AD form in discussion with their patients. Upon initiation of treatment, we filled out a supportive care checklist for each patient. The patients filled out a structured questionnaire probing their views on end-of-life discussion and awareness to supportive care resources on cycle 2 day 1 (Q1) and on cycle 3 day 1 (Q2). Results: Out of 41 screened, we completed checklists for 36 patients. Of these, 26 filled out Q1 and 11 filled out Q1 + Q2. Response rate to the questionnaires was 100%. The patients were diagnosed with metastatic solid tumor (23) and hematologic malignancies (3) and had 2 (0-5) previous lines of treatment. Females and males were 14 and 12, respectively. AD forms were filled out in most patients (81%), but about half (54%) reported having had AD discussions with their physicians. Most patients (73%) were aware of supportive resources (palliative care, social worker, support groups), and most (62%) actually used them while on study. Agreement in Q1 and Q2 was comparable (Table), with some rise in agreement with the timing of AD discussion. Conclusions: In the context of treatment on clinical trials, a large-scale initiative is feasible. More patients agree with time that early discussion of AD meets their goals while almost half report having had no such discussion with their physicians. [Table: see text]


Author(s):  
James Alton Croker ◽  
Julie Bobitt ◽  
Sara Sanders ◽  
Kanika Arora ◽  
Keith Mueller ◽  
...  

Introduction: Between 2013 and 2019, Illinois limited cannabis access to certified patients enrolled in the Illinois Medical Cannabis Program (IMCP). In 2016, the state instituted a fast-track pathway for terminal patients. The benefits of medicinal cannabis (MC) have clear implications for patients near end-of-life (EOL). However, little is known about how terminal patients engage medical cannabis relative to supportive care. Methods: Anonymous cross-sectional survey data were collected from 342 terminal patients who were already enrolled in ( n = 19) or planning to enroll ( n = 323) in hospice for EOL care. Logistic regression models compare patients in the sample on hospice planning vs. hospice enrollment, use of palliative care vs. hospice care, and use standard care vs non-hospice palliative care. Results: In our sample, cancer patients ( OR = 0.21 (0.11), p < .01), and those who used the fast-track application into the IMCP ( OR = 0.11 (0.06), p < .001) were less likely to be enrolled in hospice. Compared to patients in palliative care, hospice patients were less likely to report cancer as their qualifying condition ( OR = 0.16 (0.11), p < .01), or entered the IMCP via the fast-track ( OR = 0.23 (0.15), p < .05). Discussion: Given low hospice enrollment in a fairly large EOL sample, cannabis use may operate as an alternative to supportive forms of care like hospice and palliation. Clinicians should initiate conversations about cannabis use with their patients while also engaging EOL Care planning discussions as an essential part of the general care plan.


2018 ◽  
Vol 21 (2) ◽  
pp. 62-71
Author(s):  
Henry O’Lawrence ◽  
Rohan Chowlkar

Purpose The purpose of this paper is to determine the cost effectiveness of palliative care on patients in a home health and hospice setting. Secondary data set was utilized to test the hypotheses of this study. Home health care and hospice care services have the potential to avert hospital admissions in patients requiring palliative care, which significantly affects medicare spending. With the aging population, it has become evident that demand of palliative care will increase four-fold. It was determined that current spending on end-of-life care is radically emptying medicare funds and fiscally weakening numerous families who have patients under palliative care during life-threatening illnesses. The study found that a majority of people registering for palliative and hospice care settings are above the age group of 55 years old. Design/methodology/approach Different variables like length of stay, mode of payment and disease diagnosis were used to filter the available data set. Secondary data were utilized to test the hypothesis of this study. There are very few studies on hospice and palliative care services and no study focuses on the cost associated with this care. Since a very large number of the USA, population is turning 65 and over, it is very important to analyze the cost of care for palliative and hospice care. For the purpose of this analysis, data were utilized from the National Home and Hospice Care Survey (NHHCS), which has been conducted periodically by the Centers for Disease Control and Prevention’s National Center for Health Statistics. Descriptive statistics, χ2 tests and t-tests were used to test for statistical significance at the p<0.05 level. Findings The Statistical Package for Social Sciences (SPSS) was utilized for this result. H1 predicted that patients in the age group of 65 years and up have the highest utilization of home and hospice care. This study examined various demographic variables in hospice and home health care which may help to evaluate the cost of care and the modes of payments. This section of the result presents the descriptive analysis of dependent, independent and covariate variables that provide the overall national estimates on differences in use of home and hospice care in various age groups and sex. Research limitations/implications The data set used was from the 2007 NHHCS survey, no data have been collected thereafter, and therefore, gap in data analysis may give inaccurate findings. To compensate for this gap in the data set, recent studies were reviewed which analyzed cost in palliative care in the USA. There has been a lack of evidence to prove the cost savings and improved quality of life in palliative/hospice care. There is a need for new research on the various cost factors affecting palliative care services as well as considering the quality of life. Although, it is evident that palliative care treatment is less expensive as compared to the regular care, since it eliminates the direct hospitalization cost, but there is inadequate research to prove that it improves the quality of life. A detailed research is required considering the additional cost incurred in palliative/hospice care services and a cost-benefit analysis of the same. Practical implications While various studies reporting information applicable to the expenses and effect of family caregiving toward the end-of-life were distinguished, none of the previous research discussed this issue as their central focus. Most studies addressed more extensive financial effect of palliative and end-of-life care, including expenses borne by the patients themselves, the medicinal services framework and safety net providers or beneficent/willful suppliers. This shows a significant hole in the current writing. Social implications With the aging population, it has become evident that demand of palliative/hospice care will increase four-fold. The NHHCS have stopped keeping track of the palliative care requirements after 2007, which has a negative impact on the growing needs. Cost analysis can only be performed by analyzing existing data. This review has recognized a huge niche in the evidence base with respect to the cost cares of giving care and supporting a relative inside a palliative/hospice care setting. Originality/value The study exhibited that cost diminishments in aggressive medications can take care of the expenses of palliative/hospice care services. The issue of evaluating result in such a physically measurable way is complicated by the impalpable nature of large portions of the individual components of outcome. Although physical and mental well-being can be evaluated to a certain degree, it is significantly more difficult to gauge in a quantifiable way, the social and profound measurements of care that help fundamentally to general quality of care.


2019 ◽  
Vol 57 (2) ◽  
pp. 233-240 ◽  
Author(s):  
Robert Gramling ◽  
Elizabeth Gajary-Coots ◽  
Jenica Cimino ◽  
Kevin Fiscella ◽  
Ronald Epstein ◽  
...  

2021 ◽  
Author(s):  
Johanna Sommer ◽  
Christopher Chung ◽  
Dagmar M. Haller ◽  
Sophie Pautex

Abstract Background: Patients suffering from advanced cancer often loose contact with their primary care physician (PCP) during oncologic treatment and palliative care is introduced very late.The aim of this pilot study was to test the feasibility and procedures for a randomized trial of an intervention to teach PCPs a palliative care approach and communication skills to improve advanced cancer patients’ quality of life. Methods: Observational pilot study in 5 steps. 1) Recruitment of PCPs. 2) Intervention: training on palliative care competencies and communication skills addressing end-of-life issues.3) Recruitment of advanced cancer patients by PCPs. 4) Patients follow-up by PCPs, and assessment of their quality of life by a research assistant 5) Feedback from PCPs using a semi-structured focus group and three individual interviews with qualitative deductive theme analysis.Results: 8 PCPs were trained. PCPs failed to recruit patients for fear of imposing additional loads on their patients. PCPs changed their approach of advanced cancer patients. They became more conscious of their role and responsibility during oncologic treatments and felt empowered to take a more active role picking up patient’s cues and addressing advance directives. They developed interprofessional collaborations for advance care planning. Overall, they discovered the role to help patients to make decisions for a better end-of-life.Conclusions: PCPs failed to recruit advanced cancer patients, but reported a change in paradigm about palliative care. They moved from a focus on helping patients to die better, to a new role helping patients to define the conditions for a better end-of-life.Trial registration : The ethics committee of the canton of Geneva approved the study (2018-00077 Pilot Study) in accordance with the Declaration of Helsinki


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