This article is more than 5 years old. Information may no longer be current.
New standards guidelines provide palliative care road map for practices
As health care evolves, the ability to provide evidence-based, guideline-supported cancer care will be important for all of us.
ASCO recently advanced several guidelines and quality measures related to palliative care.
These initiatives, combined with new standards from the National Cancer Center Network (NCCN) and the American College of Surgeons’ Commission on Cancer, may provide a road map for practices and cancer programs.
The challenge for practitioners will be how to implement these evolving guidelines.
|
|
The ASCO Provisional Clinical Opinion: The Integration of Palliative Care into Standard Oncology Care, posted online in February, suggests an early palliative care consultation for patients with incurable non–small cell lung cancer.
The recommendation is based on seven studies, including one by Temel and colleagues published in 2010 in The New England Journal of Medicine.
“Based on strong evidence from a phase 3 randomized controlled trial, patients with metastatic non–small cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis,” the opinion reads. “While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care — when combined with standard cancer care or as the main focus of care — leads to better patient and caregiver outcomes.”
The provisional clinical opinion also recommends incorporating another ASCO program, the Quality Oncology Practice Initiative (QOPI).
QOPI is an oncologist-led, practice-based quality improvement program. Participating hematology-oncology practices examine a series of quality measures through retrospective chart review, with the goal to create a culture of self-examination and improvement.
NCCN guidelines, as well as the Commission on Cancer Standard 2.5, require that palliative care services be available either on site or through referral.
For practical purposes, here are a list of requirements that will help practices and practitioners meet these quality measures and the evolving standard of care:
Pain assessment
QOPI requires that a pain assessment be documented by the second visit, as well as the establishment of a plan of care for documented moderate to severe pain (defined as a patient providing a pain score of more than 4 on a scale of 0 to 10).
The documentation and plan of care should include an assessment of side effects, as well as the effectiveness of the pain management plan.
Given the importance of pain control in palliative care and cancer care in general, the opportunity to assess a patient’s pain, document its intensity and establish a plan of care at each visit likely will become a quality care indicator for all practices.
Goals of care
An early patient–clinician discussion about palliative care and the goals of care is another important component of ASCO’s provisional care opinion, the Commission on Cancer standards and the NCCN guidelines.
Although evidence suggesting the effectiveness of an early discussion of palliative care and therapy choices is only available in the NSCLC subset, there is no evidence that doing so causes harm.
Thus, discussion and documentation of palliative care and goals of care should occur early in the disease trajectory. This likely will lead to improved symptom assessment and management.
Practical aspects would include documenting the goals-of-care discussion with the patient and family, as well as the development of advance care directives.
Hospice referral
The ASCO provisional clinical opinion and QOPI end-of-life measures include hospice enrollment, the length of time on hospice and documentation of whether chemotherapy was administered within the last few weeks of life.
The early palliative care in NSCLC showed that patients had better understanding of their disease, prognosis and options. They had better quality of life, received less chemotherapy, had lower rates of hospitalization and intubation, and had longer hospice enrollment.
Lack of resources
One significant limitation to implementing these recommendations and guidelines is the lack of available outpatient palliative care consultants and resources available to oncologists.
As the ASCO provisional clinical opinion suggests, establishing and advocating for these resources locally would help practitioners meet the goals.
Implementing simple office practices and electronic records with templates for notes can help meet the requirements. These templates include:
- Inclusion of pain assessment as part of vital signs.
- Documentation of advance care directives.
- Discussion and documentation of treatment choices, including hospice and palliative care, early in the disease trajectory.
How do you and your practice plan to meet these standards, guidelines and recommendations? Scan the QR code on this page to comment on this column at Healio.com/HemOnc.
References:
- ASCO. Clinical practice guidelines. Available at: www.asco.org/ASCOv2/Practice+%26+Guidelines/Guidelines/Clinical+Practice+Guidelines. Accessed March 6, 2012.
- QOPI. Program details. Available at: http://qopi.asco.org/program. Accessed March 6, 2012.
- Temel JS. N Engl J Med. 2010;363:733-742.
For more information:
- Biren Saraiya, MD, is an assistant professor at the Cancer Institute of New Jersey at UMDNJ-Robert Wood Johnson Medical School. He also is a member of the HemOnc Today Editorial Board. Disclosure: Dr. Saraiya reports no relevant financial disclosures.