Should management of a patient’s physical and psychological symptoms be handled by their oncology team?
Click here to read the Cover Story, “Palliative care flourishing but ‘significant hurdles’ remain.”
The oncology team should manage a patient’s symptoms but consult with a palliative care expert based on the patient’s specific needs. This is called needs-based palliative care.
Patients often have a devoted relationship with their oncology team based on a sacred trust that has led to excellent care and a feeling that the patient’s life has been saved or prolonged by that team. We should not disrupt that relationship or burden patients with extra, unnecessary visits.
However, there are times when outside palliative care expertise is necessary. Further, as new treatments continually evolve, keeping up with the complexity of needs is very demanding, and sometimes the oncology team can get distracted with other critical elements and may not have time for palliative care aspects. Thus, very often, team care involving a palliative care expert is needed.
This plays out as a pyramid of care. At the base of the pyramid is primary oncologic care, where the team manages the side effects of treatment and other issues that may arise from early-stage disease. Moving up the pyramid, there are times when consultations may be warranted, even if they are in an outpatient setting. Patients can move in and out of different levels of palliation need and care.
Still, the availability of such an approach is variable and depends on the environment. In academic centers, there often are resources for separate roles. That is not always the case in community hospitals, where often the oncology team has no choice but to provide palliation.
The key is integrating palliative care throughout the spectrum of oncology care. This involves having discussions about needs, values and priorities; managing symptoms throughout treatment; and having hard talks about prognosis or end-of-life matters.
Patients’ needs change throughout their treatment journeys, and many times those needs fall in the realm of what an oncologic team can handle. For other, more complex needs — such as having hard discussions or relieving refractory cancer pain — it is valuable to consult a palliative care team. Our main goals are to make people feel better and supported, improve their will and resolve, and keep them out of risky environments.
Diane Portman, MD, FAAHPM, is chair of the department of supportive care medicine at Moffitt Cancer Center and associate professor of oncologic sciences at Morsani College of Medicine at University of South Florida. She can be reached at email@example.com. Disclosure: Portman reports no relevant financial disclosures.
Teams are customarily set up with an oncologist or oncology nurse administering chemotherapy, a pharmacist mixing the chemotherapy, a medical assistant taking vital signs and getting patients in and out of examination rooms, and front-office staff dealing with the rest.
Our ability to relieve the symptoms and stress of cancer and its treatment has never been more powerful in the history of oncology. It is more than one oncologist can integrate into routine practice. Moreover, the evidence is overwhelming that this is not routinely made available in standard oncology settings.
Subspecialization is a response to new knowledge. It is a way to make that new knowledge available practically. Communication science with patients and families — particularly in the setting of “bad news” and ineffective coping skills — has made enormous progress. The family meeting for a goals-of-care conversation is, in some sense, a new procedure. The meeting takes preparation, time and skill. Symptom control — including pain, nausea, vomiting, dyspnea, pruritus and more — often is fussy. It involves polypharmacy and frequent changes of dose and route, as well as nonpharmacological approaches. When done well, patients and their families have a better quality of life and avoid repeated trips to the ED and hospital admissions. They also live longer.
Medical oncology is vastly more complex than 10 years ago; the new knowledge has increased exponentially. Coupled with the relative shortage of medical oncologists as contrasted with the rising incidence of cancer among an aging population, there is no other rational conclusion than the oncology team must expand to include specialists in palliative care — care that provides an added layer of support to patients with cancer and their families to deal with the symptoms and stress of the illness and its management.
In many places, this has evolved to oncology practices referring patients to palliative care for an additional visit in the same way they would refer to GI or endocrinology. Emerging evidence suggests this is less than optimal. Better is an expanded view of the oncology team that includes specialist physicians, nurses, social workers, chaplains and pharmacists who see patients in an embedded model right alongside the standard oncology team so that patients only need to make one visit to one place and the entire experience is managed together.
One benefit I have observed — but have not seen mentioned much in the medical literature — is for oncologists. Sharing the burden of cancer management with others helps oncologists sustain enthusiasm for their work. I believe embedding palliative care teams in standard oncology reduces turnover and burnout of oncology professionals. In one program I developed, that was the driver — the turnover of medical oncologists was 50% per year. Once the embedded palliative care team was operating, that dropped to zero.
Charles F. von Gunten, MD, PhD, is a palliative care specialist and vice president of medical affairs at OhioHealth. He can be reached at firstname.lastname@example.org. Disclosure: von Gunten reports no relevant financial disclosures.