Conceptual models for integrating palliative care at cancer centers

Abstract

Palliative care programs are rapidly evolving in acute care facilities. Increased and earlier access has been advocated for patients with life-threatening illnesses. Existing programs would need major growth to accommodate the increased utilization. The objective of this review is to provide an update on the current structures, processes, and outcomes of the Supportive and Palliative Care Program at the University of Texas M.D. Anderson Cancer Center (UTMDACC), and to use the update as a platform to discuss the challenges and opportunities in integrating palliative and supportive services in a tertiary care cancer center. Our interprofessional program consists of a mobile consultation team, an acute palliative care unit, and an outpatient supportive care clinic. We will discuss various metrics including symptom outcomes, quality of end-of-life care, program growth, and financial issues. Despite the growing evidence to support early palliative care involvement, referral to palliative care remains heterogeneous and delayed. To address this issue, we will discuss various conceptual models and practical recommendations to optimize palliative care access.

FIG. 1.

Number of palliative care referrals between 2000 and 2011. Both inpatient and outpatient palliative care programs show steady growth.

FIG. 2.

Proportion of inpatient death occurring in medical Intensive Care Units (ICU) between 2001 and 2009. A high proportion of patients without a palliative care consultation died in the ICU, and this continues to increase. In contrast, the percentage of medical ICU death stayed consistently low among patients with a palliative care consultation.

FIG. 3.

Patterns and process of referral for supportive care services. (A) Cancer patients presenting with severe symptoms may be referred to different supportive care services depending on which symptom is detected and the referral practice for each oncologist. This ranges from no referral at all (doctors C, D, and E), to involvement of selected services (doctors A and B) to palliative care referral (doctor F). (B) In this model of comprehensive cancer care, all patients with severe distress are referred to palliative care, and receive comprehensive assessment for their symptoms, communication and decision making needs, with the appropriate management provided by physicians, nurses, and counselors. Those with specific needs are then further referred to other services. This model ensures that supportive palliative care is delivered in a comprehensive, personalized and streamlined fashion.

FIG. 4.

Conceptual framework for “Supportive Care,” “Palliative Care,” and “Hospice Care.” “Hospice Care” is part of “Palliative Care,” which in turn is under the umbrella of “Supportive Care.” “Palliative Care” predominantly addresses the care needs for patients with advanced cancer in both acute care facilities and the community, whereas “Supportive Care” provides an even broader range of services for patients throughout various stages of the disease, including diagnosis, active treatment, end-of-life, and survivorship.

FIG. 5.

Conceptual model for Goals of Car(e). A car is used here as an analogy for establishing goals of care. (A) A hopeful unrealistic driver believes that there will be no troubles ahead in her journey. This is in contrasts to (B) a hopeful realistic driver who understands the importance of comfort measures and the need to prepare for the trip ahead. (C) A hopeful unrealistic patient who focuses on cancer treatments without attention to her symptoms and advance care needs may experience unnecessary distress. (D) In contrast, a hopeful and realistic patient who receives concurrent oncologic and supportive/palliative care would be better prepared for the symptoms and care needs ahead. Abbreviations: CPR, cardiopulmonary resuscitation; ER, emergency room; ICU, intensive care unit. Reprinted with permission from MD Anderson Cancer Center.

FIG. 6.

The cancer care package. (A) In the Solo Practice Model, the oncologist provides both cancer assessment and treatment, and addresses a variety of supportive care issues such as pain and dyspnea. However, the lack of time and expertise means that these issues may not be managed adequately. (B) In the Congress Practice Model, the oncologist refers the patient to various specialities for all the supportive care issues. This could result in fragmented and expensive care. (C) In the Integrated Care Model, the oncologist routinely refers patients to palliative care for their supportive care needs. This helps to ensure patients receive comprehensive and integrated care, and it streamlines the provision of care. Reprinted with permission from MD Anderson Cancer Center.

FIG. 7.

Criteria for palliative care referral. A typical oncology practice consists of high-demand patients and low-demand patients. High-demand patients with physical or emotional distress, refractory disease, or need for transition of care would benefit from routine referral to supportive care for further management.