EditorialPublication Exclusive

Palliative medicine under the microscope: Not every patient with cancer needs palliative care

In this edition of HemOnc Today, we cover the important topic of palliative management.

In particular, we review the Oncology Nursing Society’s (ONS) recently published position statement on this issue.

Nurses are among the strongest and most effective patient advocates, and it is pleasing to see them take a strong position on this crucial issue.

Derek Raghavan

Derek Raghavan

Our nursing colleagues were preceded by ASCO, which issued its own position paper in 1998 supporting the importance of palliative and hospice medicine in the management of advanced cancer, then followed up in 2009 to assess its level of impact and the extent of change during the subsequent decade.

The earlier paper focused on the importance of continuity of care by the oncologist, including symptom control and psychosocial support during all phases of care for advanced cancer — including the terminal stages — and addressed extant barriers to optimal palliative and supportive care.

The follow-up paper illustrated the substantial progress during the subsequent decade, particularly in the domains of documentation of the causes of suffering, development of educational programs, the evolution of national and international organization and collaboration, the creation of guidelines and good-practice algorithms, the insertion of these standards into the Quality Oncology Practice Initiative and other quality assessment programs, and the beginnings of serious palliative care research.

It culminated in a vision for the future. Unfortunately, it also was clear that major impediments continued to obstruct the best outcomes, including the territorial imperative, lack of team-based care, and physician inability to create optimal analgesia with lack of attention to other symptoms, partly predicated on inadequate approaches to securing correct information on the extent of symptoms and distress.

As is well known, these issues were often compounded by lack of forthright discussion about prognosis and realistic expectations about the likely results of further active therapy.

‘No scope for error’

With a very similar ethos, the ONS position is essentially this:

  • All patients with cancer benefit from palliative care, which should be initiated at diagnosis and continue through bereavement;
  • Physical, psychological, social, cultural, and spiritual assessments and management are key items;
  • The family is the unit of care;
  • This work should be done by an inter-professional team;
  • Focus on family needs and communication to enable transfer of this information constitute a sine qua non for optimal cancer care;
  • Oncology nurses require training in the key, broad elements of palliative management, and they are uniquely positioned to act as patient advocates; and
  • Advanced directives are crucially important and must be followed.
  • So, why write another editorial on this topic?

    Obviously, this is a critically important issue in the management of cancer, and it is pleasing that our medical and nursing organizations have aligned with similar aims in this domain. The ONS statement will be extremely influential, and thus has no scope for error.

    It seems to me, in a time of resource constraint, that the important domain of palliative management — having been strongly advocated — also needs to be rationalized. We must create the right algorithms that maintain a balance that favors excellent and necessary care.

    What caught my eye in the ONS statement was the phrase “all patients with cancer benefit from palliative care” and the emphasis on team medicine for everything within this construct. I just don’t agree with that view, nor do I see the implicit — and explicit — downstream impact as making clinical or fiscal sense.

    I completely support the importance of team palliative and supportive medicine, and the need for symptomatic patients — including those whose only symptom is distress — to be managed appropriately. However, an encyclical that supports the unstructured use of any therapeutic modality without a defined reason is problematic.

    Identifiable needs, measurable benefits

    In my view, the first and most critical step is to identify need. This means that the standard and time-honored H&P must focus in more detail on all of the symptoms attendant on cancer — including the psychosocial and fiscal ones — and probably should be augmented by the newer electronic tools that are available: electronically predicated distress scales, requirement for specific information before an electronic medical record can be closed out, etc.

    Perhaps it is just a function of terminology, but I do not appreciate the broad use of the term “palliative medicine” and believe that we need to identify a more precise continuum of offerings. “Supportive medicine and symptom control” fits very nicely for the needs of the patient on active treatment who may have less severe or transient disease-/treatment-related issues. In my ideal vernacular, “palliative medicine” fits more appropriately into the ASCO construct of the broad panoply of symptom control for patients with advanced disease, and may ultimately graduate within that continuum into hospice care.

    My point is relatively simple: In an era of cost containment and limited resources, the medical and nursing professions increasingly must be able to justify their formal recommendations, focusing them on identifiable need and measurable benefits.

    It would be extremely hard to question the benefits of palliation for patients with intractable disease. Clearly, these include better quality of life, improved management of the family–patient unit, better after-care for the family consequent upon a death and, importantly, a much more humane and cost-effective approach to treatment of the patient. At a community level, a litany of studies have shown conclusively that active treatment is an expensive option that affords little benefit — and often creates harm — to the dying patient, and is effectively and appropriately replaced by timely referral for palliative and then hospice care.

    That said, the thought that all patients with cancer should receive palliative care — or an integrated, team-based approach — just doesn’t make sense to me as clinician with 40 years of experience. There are many patients who can comfortably handle the diagnosis and understand the issues regarding treatment, and who have mild to moderate levels of anxiety or other symptoms that can be handled at a simple level by an engaged and caring physician and the immediate support staff.

    This particularly applies to patients dealing with nonmetastatic cancer who have a fine prognosis, simple treatment options, adequate insurance and adequate levels of education, and who indicate on simple questionnaires or via direct questioning that they are in adequate control of the situation. In the model that we have developed, for the patient with curable cancers, a focus on survivorship is crucial, but this is very different from a focus on “palliation.”

    Even in this modern era of regimentation and organized medicine (and reimbursement), with the move toward team management for everything, the rational use of palliative resources will allow us to focus them more effectively for patients and families dealing with advanced disease, who actually need them.

    With that construct, it remains possible for empathetic and well-trained physicians and their staffs — with structured and appropriate clinical pathways — to provide for their patients a life “beautiful like summer flowers and death like autumn leaves,” the memorable phrasing of the Indian poet Rabindranath Tagore.

    References:

    ASCO. Cancer Care During the Last Phase of Life. Available at: jco.ascopubs.org/site/misc/16.5.1986.pdf. Accessed on March 9, 2015.
    Ferris FD. J Clin Oncol. 2009;doi:10.1200/JCO.2008.20.1558.
    Oncology Nursing Society. Oncol Nurs Forum. 2015;42:11-12.

    For more information:

    Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.

    Disclosure: Raghavan reports no relevant financial disclosures.

    In this edition of HemOnc Today, we cover the important topic of palliative management.

    In particular, we review the Oncology Nursing Society’s (ONS) recently published position statement on this issue.

    Nurses are among the strongest and most effective patient advocates, and it is pleasing to see them take a strong position on this crucial issue.

    Derek Raghavan

    Derek Raghavan

    Our nursing colleagues were preceded by ASCO, which issued its own position paper in 1998 supporting the importance of palliative and hospice medicine in the management of advanced cancer, then followed up in 2009 to assess its level of impact and the extent of change during the subsequent decade.

    The earlier paper focused on the importance of continuity of care by the oncologist, including symptom control and psychosocial support during all phases of care for advanced cancer — including the terminal stages — and addressed extant barriers to optimal palliative and supportive care.

    The follow-up paper illustrated the substantial progress during the subsequent decade, particularly in the domains of documentation of the causes of suffering, development of educational programs, the evolution of national and international organization and collaboration, the creation of guidelines and good-practice algorithms, the insertion of these standards into the Quality Oncology Practice Initiative and other quality assessment programs, and the beginnings of serious palliative care research.

    It culminated in a vision for the future. Unfortunately, it also was clear that major impediments continued to obstruct the best outcomes, including the territorial imperative, lack of team-based care, and physician inability to create optimal analgesia with lack of attention to other symptoms, partly predicated on inadequate approaches to securing correct information on the extent of symptoms and distress.

    As is well known, these issues were often compounded by lack of forthright discussion about prognosis and realistic expectations about the likely results of further active therapy.

    ‘No scope for error’

    With a very similar ethos, the ONS position is essentially this:

  • All patients with cancer benefit from palliative care, which should be initiated at diagnosis and continue through bereavement;
  • Physical, psychological, social, cultural, and spiritual assessments and management are key items;
  • The family is the unit of care;
  • This work should be done by an inter-professional team;
  • Focus on family needs and communication to enable transfer of this information constitute a sine qua non for optimal cancer care;
  • Oncology nurses require training in the key, broad elements of palliative management, and they are uniquely positioned to act as patient advocates; and
  • Advanced directives are crucially important and must be followed.
  • So, why write another editorial on this topic?

    Obviously, this is a critically important issue in the management of cancer, and it is pleasing that our medical and nursing organizations have aligned with similar aims in this domain. The ONS statement will be extremely influential, and thus has no scope for error.

    It seems to me, in a time of resource constraint, that the important domain of palliative management — having been strongly advocated — also needs to be rationalized. We must create the right algorithms that maintain a balance that favors excellent and necessary care.

    What caught my eye in the ONS statement was the phrase “all patients with cancer benefit from palliative care” and the emphasis on team medicine for everything within this construct. I just don’t agree with that view, nor do I see the implicit — and explicit — downstream impact as making clinical or fiscal sense.

    I completely support the importance of team palliative and supportive medicine, and the need for symptomatic patients — including those whose only symptom is distress — to be managed appropriately. However, an encyclical that supports the unstructured use of any therapeutic modality without a defined reason is problematic.

    PAGE BREAK

    Identifiable needs, measurable benefits

    In my view, the first and most critical step is to identify need. This means that the standard and time-honored H&P must focus in more detail on all of the symptoms attendant on cancer — including the psychosocial and fiscal ones — and probably should be augmented by the newer electronic tools that are available: electronically predicated distress scales, requirement for specific information before an electronic medical record can be closed out, etc.

    Perhaps it is just a function of terminology, but I do not appreciate the broad use of the term “palliative medicine” and believe that we need to identify a more precise continuum of offerings. “Supportive medicine and symptom control” fits very nicely for the needs of the patient on active treatment who may have less severe or transient disease-/treatment-related issues. In my ideal vernacular, “palliative medicine” fits more appropriately into the ASCO construct of the broad panoply of symptom control for patients with advanced disease, and may ultimately graduate within that continuum into hospice care.

    My point is relatively simple: In an era of cost containment and limited resources, the medical and nursing professions increasingly must be able to justify their formal recommendations, focusing them on identifiable need and measurable benefits.

    It would be extremely hard to question the benefits of palliation for patients with intractable disease. Clearly, these include better quality of life, improved management of the family–patient unit, better after-care for the family consequent upon a death and, importantly, a much more humane and cost-effective approach to treatment of the patient. At a community level, a litany of studies have shown conclusively that active treatment is an expensive option that affords little benefit — and often creates harm — to the dying patient, and is effectively and appropriately replaced by timely referral for palliative and then hospice care.

    That said, the thought that all patients with cancer should receive palliative care — or an integrated, team-based approach — just doesn’t make sense to me as clinician with 40 years of experience. There are many patients who can comfortably handle the diagnosis and understand the issues regarding treatment, and who have mild to moderate levels of anxiety or other symptoms that can be handled at a simple level by an engaged and caring physician and the immediate support staff.

    This particularly applies to patients dealing with nonmetastatic cancer who have a fine prognosis, simple treatment options, adequate insurance and adequate levels of education, and who indicate on simple questionnaires or via direct questioning that they are in adequate control of the situation. In the model that we have developed, for the patient with curable cancers, a focus on survivorship is crucial, but this is very different from a focus on “palliation.”

    Even in this modern era of regimentation and organized medicine (and reimbursement), with the move toward team management for everything, the rational use of palliative resources will allow us to focus them more effectively for patients and families dealing with advanced disease, who actually need them.

    With that construct, it remains possible for empathetic and well-trained physicians and their staffs — with structured and appropriate clinical pathways — to provide for their patients a life “beautiful like summer flowers and death like autumn leaves,” the memorable phrasing of the Indian poet Rabindranath Tagore.

    References:

    ASCO. Cancer Care During the Last Phase of Life. Available at: jco.ascopubs.org/site/misc/16.5.1986.pdf. Accessed on March 9, 2015.
    Ferris FD. J Clin Oncol. 2009;doi:10.1200/JCO.2008.20.1558.
    Oncology Nursing Society. Oncol Nurs Forum. 2015;42:11-12.

    For more information:

    Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.

    Disclosure: Raghavan reports no relevant financial disclosures.