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How oncologists can deal with palliative and end-of-life care
How do you view your role when it comes to the end-of-life discussion with patients?
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In a recent column, I discussed caring for the whole patient and recommended the use of a tool such as the NCCN’s Distress Thermometer to assess for distress and its cause. The other aspect of caring for patients is discussing end-of-life care.
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In a recent article in Journal of Palliative Medicine, Dr. Vicki Jackson reported findings of a survey and qualitative interviews of oncologists whose patients had recently died in the hospital. This study included both solid tumors and transplant oncologists. The study identified several areas where the oncologists differed in their approach to their patients. These areas included how oncologists viewed their role, how oncologists approached patients and families, and the potential impact of these interactions on themselves.
The study identified two groups of oncologists. The first group of oncologists felt that their role was to treat the biomedical and psychosocial issues of the patients. These oncologists were more likely to have an approach to discussing end-of-life care issues as a “process involving multiple conversations.” They were also more likely to make individualized recommendations, felt satisfied with their care and scored lower on a burnout questionnaire.
The second group of oncologists primarily focused their efforts on the biomedical issues, did not identify a specific approach to addressing end-of-life care issues, did not make specific recommendations and felt “a sense of failure.” Most importantly, this group of oncologists felt that they had less collegial support and scored higher on the burnout scale.
In the article’s accompanying editorial, Dr. Charles von Gunten made recommendations for palliative care clinicians working with oncologists. He recommended that the palliative care team routinely assume “the end-of-life care responsibilities without any shame” when working with a second group of oncologists.
I was afraid that he was recommending that palliative care clinicians should come in as saviors for our patients and take over their care. I spoke to Dr. von Gunten to better understand his recommendation.
“Being good consultants,” von Gunten recommended that “palliative care clinicians should help” oncologists work better. He added that some oncologists’ interest lies with the biomedical issues and they may not want to address psychosocial and end-of-life care issues. Palliative care clinicians can work with these oncologists from the beginning and become part of the treatment team and provide optimal care for patients.
Von Gunten cited his experience at the Moores Cancer Center in San Diego where he and his colleagues in palliative care work alongside their oncology colleagues and tailor their involvement and interventions based on the oncologists’ need. For those oncologists who feel comfortable dealing with psychosocial and end-of-life care issues, the involvement of palliative care clinicians may be minimal.
From a practical aspect of delivery of care, most patients are cared for in a community where resources like palliative care clinicians may be limited. The idea of having a team of clinicians taking care of patients is a good one and there are several models, including the one at Moores Cancer Center, where it seems to be successful. However, until we get to utopia, where every oncologist has access to a palliative care physician — oncologists will be required to address end-of-life care issues and thus should be prepared in training.
Though Dr. Jackson’s study does not specify why one group of oncologists felt more burnt out, I wondered if having a framework to discuss these difficult issues makes a difference. Having participated in Oncotalk (http://depts.washington.edu/oncotalk/learn/), a communication skills training as a fellow, I believe that addressing end-of-life issues is a set of skills that can be taught and learned.
Dr. von Gunten wondered if there are some who are more comfortable with the biomedical issues and not with psychosocial issues regardless of training. He recommended that training programs should offer fellows opportunities to work with mentors who possess the skills to address psychosocial and end-of-life care issues with their patients. I have a stronger recommendation.
Communication skills are so important that they should not be left to chance; all training programs should provide fellows with the basic knowledge and principles of communication skills, maybe even based on Oncotalk.
Biren Saraiya, MD, is an Assistant Professor in Hematology-Oncology at the Cancer Institute of New Jersey at UMDNJ-Robert Wood Johnson Medical School and is a member of the HemOnc Today Editorial Board.
For more information:
- Jackson V, et al. A qualitative study of oncologists’ approaches to end of life care. J Palliat Med. 2008;11:893.
- von Gunten CF. Oncologists and end-of-life care. Palliat Med. 2008;11:813.
- Back AL, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167: 453-460.