ASCO, AAHPM issue guidance statement on hospice, palliative care in oncology practice

ASCO and the American Academy of Hospice and Palliative Medicine have issued a guidance statement outlining strategies for high-quality palliative care delivered by oncologists to patients with advanced cancers or high symptom burden.

Perspective from Cardinale Smith, MD, MSCR

The statement was released in conjunction with the Palliative Care in Oncology Symposium.

Palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction when integrated into routine oncology practice. However, not all oncology practices have access to subspecialty palliative medicine for referral, according to the researchers.

“The small workforce of palliative care specialists are insufficient to meet the needs of all patients with cancer in the U.S. who might benefit from these services,” Kathleen E. Bickel, MD, MPhil, assistant professor of medicine at Dartmouth College’s Geisel School of Medicine, said during a press conference. “Thus, alternative treatment models are being sought. Oncologists can — and already do — provide many palliative services, but until now, no comprehensive guidance existed on what practices should be aiming to provide.”

Bickel and colleagues sought to define what constitutes high-quality primary palliative care as delivered by medical oncology practices.

The expert steering committee developed a list of 966 palliative care service items, which they divided into nine domains. Each domain referred to an aspect of palliative care delivery for patients with advanced cancer.

A group of panelists ranked each service item according to importance, feasibility, and scope.

The panelists endorsed the highest proportion of palliative care service items in the following domains: end-of-life care (81%), communication and shared decision-making (79%), and care planning (78%).

They endorsed the lowest proportion of services in the following domains: spiritual and cultural assessment and management (35%) and psychosocial assessment and management (39%).

In the largest domain — symptom assessment and management — the panelists reached consensus that all symptoms should be assessed and managed at a basic level, with more comprehensive management for common symptoms like nausea, vomiting, diarrhea, dyspnea and pain.

Within the domain of appropriate palliative care and hospice referral, the panelists reached consensus that oncology practices should be able to describe the difference between palliative care and hospice service to patients and to refer patients with a projected survival of less than 3 months or poor performance status to hospice.

“A full publication will be coming soon, with more details about the specific service items included in this definition project,” Bickel said. “This is necessary because in order to improve palliative care delivery and access for patients with cancer, we must first define and agree on what oncology practices should be providing.” – by Cameron Kelsall

Reference:

Bickel KE, et al. Abstract 108. Scheduled for presentation at: Palliative Care in Oncology Symposium; October 9-10, 2015; Boston.

Disclosure: Bickel reports no relevant financial disclosures. Please see the full abstract for a list of all other researchers’ relevant financial disclosures.

Perspective

Cardinale Smith, MD, MSCR

Being able to provide primary palliative care is paramount for providing excellent, quality care to all patients with cancer. This is especially important as the majority of patients with cancer in the United States receive care outside of highly resourced academic cancer centers, where specialty-level palliative care services are more likely to be available. Our current health care system is too stressed to accommodate outpatient specialty-level palliative care for all patients with cancer and, therefore, primary oncologists should have basic palliative care knowledge. However, there has been no true definition of primary palliative care in oncology.
This guideline presented by Bickel and colleagues provides the first formal consensus-based recommendations regarding the types of palliative care services that constitute high-quality primary palliative care in oncology.
Researchers identified nine palliative care domains, with the largest items falling into the symptom-management domain. This seems appropriate given that symptom burden is a major issue patients face from the cancer itself and from the treatments for the cancer. Further, the areas of highest consensus were that of end-of-life care and communication and shared-decision making. Palliative care is still viewed by many to be associated with end-of-life care, which is evidenced by the consensus on this committee. As a group we must move away from this ideology and transition palliative care more upstream to ensure patients receive the most benefit. I am encouraged that consensus was also high in the communication domain. This is a critical component of providing high-quality cancer care.
Overall, this is a great endeavor on behalf of two large organizations with the ability to promote change. The committee identified a total of 966 palliative care service items that seem to be quite comprehensive and, I imagine, overwhelming and burdensome. As with most guidelines, telling providers what to do is very different than how to do it — particularly for busy practitioners. I applaud this initial effort and look forward to seeing the final guideline once it is published.

Cardinale Smith, MD, MSCR

Icahn School of Medicine at Mount Sinai

Disclosures: Smith reports no relevant financial disclosures.