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Putting early palliative care into practice
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In the Aug. 19 issue of The New England Journal of Medicine, investigators from Massachusetts General Hospital reported that early palliative care interventions in patients with advanced lung cancer had better quality of life and mood, received less aggressive care at the end of life and had improved survival.
This study’s findings raise some interesting issues as identified by the accompanying editorial by Drs. Kelly and Meier, including one that I want to discuss in this column. How can I improve my patient’s quality of life, provide the care they want and increase survival in the absence of dedicated outpatient palliative care service?
In the study, patients in the early palliative group met with a palliative care physician or advanced practice nurse within 3 weeks of enrollment and then monthly in the outpatient setting until death. The focus of the palliative care consultation was to inquire about the illness and the patient’s understanding of prognosis, offer clarity of treatment goals, assess and help treat symptoms, and help with decision-making and coping.
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As an oncologist, I would like to provide these services to my patients in an informal but focused manner before the illness reaches a crisis point. What can I do going forward? Some suggestions are:
- Hold periodic discussions with the patient to assess his or her understanding of the illness and its implications;
- Assess symptoms systematically. At every visit, assess the effect of the symptom-relief plan;
- Assess coping and the need for additional social support.
When discussing patients’ perceptions and understanding of illness and its implications, I often keep the following graph in mind (see Figure 1.) This is a depiction of the function of patients with cancer in the last 12 months of life.
The graph shows that patients may have good performance status until the last few months of life, and we can presume that most patients go through two to three lines of chemotherapy in the preceding months with relatively good performance status.
But like many oncologists, I feel most comfortable in my ability to manage a patient’s symptoms when I am focused on symptom management. To avoid overlooking these symptoms, I often create a separate problem list for symptoms. If necessary, I will refer the patient to my colleagues for specific symptoms.
At my institution, we have social workers who can help with the final bullet point, so I use them for all my patients, not just those who are obviously in distress. The goal is that the social worker helps with the patient’s emotional needs and assists with social support, including transportation, finances and screening for additional psychiatric support.
Under these assumptions, I will continue my practice of assessing the patient’s need for information and discussing the patient’s goals of care from the beginning of the disease. I’ll ask questions such as:
- What is your understanding of what other doctors (or I) have told you?
- What things are important to you? For some patients, how long they live is the most important thing without regard for how well they live. For some, the opposite is true. Most of us fall somewhere in between – where do you see yourself?
- What does that mean to you? How do you want to live your life, or how does that affect how you want to live your life?
I’ll also reassess patients’ goals using similar questions periodically. Often a change in therapy or during restaging is a good time for these discussions.
In terms of my discussion of goals of therapy, I continue to be absolutely clear with patients in the simplest terms, whether the cancer is curable or not. If it’s not curable, then the goal can only be palliative; in that case, I would offer hospice as a treatment option, even at the first meeting and new diagnosis.
My approach is that I am going to have to have a difficult discussion of transitions to hospice at some point in time. By doing it as early as possible on the first visit, I provide my patients with the knowledge of all of the options that are ultimately available to them. Offering options does not necessarily mean I recommend the option.
I wonder if HemOnc Today readers would share their thoughts on my palliative care plan and offer some of their own suggestions and case studies. Please send me a note at saraiybi@umdnj.edu.
For more information:
- Kelley AS. N Engl J Med. 2010;363:781-782
- Temel JS. N Engl J Med. 2010;363:733-742