Integrating palliative care into the trajectory of cancer care

Abstract

Over the past five decades, palliative care has evolved from serving patients at the end of life into a highly specialized discipline focused on delivering supportive care to patients with life-limiting illnesses throughout the disease trajectory. A growing body of evidence is now available to inform the key domains in the practice of palliative care, including symptom management, psychosocial care, communication, decision-making, and end-of-life care. Findings from multiple studies indicate that integrating palliative care early in the disease trajectory can result in improvements in quality of life, symptom control, patient and caregiver satisfaction, illness understanding, quality of end-of-life care, survival, and costs of care. In this narrative Review, we discuss various strategies to integrate oncology and palliative care by optimizing clinical infrastructures, processes, education, and research. The goal of integration is to maximize patient access to palliative care and, ultimately, to improve patient outcomes. We provide a conceptual model for the integration of supportive and/or palliative care with primary and oncological care. We also discuss how health-care systems and institutions need to tailor integration based on their resources, size, and the level of primary palliative care available.

Figure 1

Conceptual framework for supportive care, palliative care and hospice care, based on a systematic literature review. Supportive care is defined as “the provision of the necessary services for those living with or affected by cancer to meet their informational, emotional, spiritual, social or physical need during their diagnostic treatment or follow-up phases encompassing issues of health promotion and prevention, survivorship, palliation and bereavement.” Palliative care is supportive care for patients with advanced-stage disease, and includes interventional programmes used in both acute-care hospitals and the community. Hospice care is a form of community-based palliative care predominantly serving patients and their loved-ones at the end of life. Under this conceptual framework, hospice care is a branch of palliative care, and palliative care is, in turn, a branch of supportive care. Supportive care also include many other services such as teams that manage cancer treatment related toxicities and cancer related complications (e.g. dermatologists who treat epidermal growth factor related rash, and pulmonologists who provide endoscopy and airway stenting), wound care teams, psychosocial oncology, social workers and chaplains. Bereavement care refers to support provided to family caregivers after the death of the patient, and may last for months to a year or longer.

Figure 2

Indicators of successful integration of palliative care into oncology practice. Previously, we reviewed the literature to identify factors relevant to different aspects that are associated with efforts to integrate palliative care into clinical practice in oncology; we identified four indicators related to clinical structure, 13 indicators related to clinical processes, eight related to education, four related to research, and nine related to administration.^, Subsequently, a Delphi study of international experts identified 13 major (>90% consensus) indicators and 30 minor (70–90% consensus) indicators of integration. Major indicators were defined as the most relevant and important indicators related to integration. Eight of the major indicators are highlighted with an asterisk and 5 represented new additions (i.e. routine documentation of advance care plans in patients with advanced cancer; proportion of outpatients with pain assessed on either of the last two visits before death; proportion of patients with 2 or more emergency room visits in last 30 days of life; place of death consistent with patient’s preference; combined educational activities for palliative care and oncology fellows/trainees). These indicators represent strategies to improve efforts to combine these disciplines of care. Furthermore, these indicators may be used to assess the level of integration, which can in turn allow patients and clinicians to identify cancer centers that offer high level of palliative care access, policy makers and administrators to conduct program evaluation and allocate appropriate resources to improve care, educators to develop curriculum, and researchers to assess how integration can improve outcomes.

Figure 3

Care needs of patients with advanced-stage cancer. a the care needs of a patient with cancer can be classified under three domains: cancer management; symptom management and personal care needs; and the management of comorbidities. Considerable interactions exist between these domains and, therefore, interventions relating to one domain of care can influence the needs pertaining to another (arrows), which necessitates dynamic monitoring of the patient and modification of their care. For instance, chemotherapeutic agents can cause renal failure, which requires the initiation of different medical interventions and can also affect the ability of the patient to proceed with oncological investigations and treatments. Disease progression might affect the emotional state of the patient, which might, in turn, affect her adherence to treatment. To optimize patient outcomes, the oncology team, palliative-care team, primary-care team, and other subspecialists need to collaborate closely and communicate often. b Personal care needs can be further subdivided into acute issues, chronic issues, psychosocial issues, and existential and spiritual issues. Relevant expertise, close collaboration and interdisciplinary teamwork, and adequate resources are important requirements to comprehensively address these supportive-care issues, longitudinally.

Figure 4

Management of personal care needs. The diagrams depict schematically how different health-care teams can address the personal needs of patients with cancer, including the acute issues, chronic issues, psychosocial issues, and existential issues. a Oncology teams have an important role providing primary palliative care; however, addressing all personal care needs comprehensively might be difficult for these teams, owing to time constraints, a lack of routine screening, unavailability of interdisciplinary team members, and limited advanced expertise in supportive-care issues. b Psychosocial teams often have a narrow focus for palliative care (for example, spirituality for chaplains, anxiety and depression for psychologists and psychiatrists, family and financial issues for social workers, child care for child-life specialists), and rarely address physical symptoms fully. c Palliative-care teams, because of their interdisciplinary nature and expertise, can comprehensively manage the personal care needs of patients longitudinally.

Figure 5

Palliative care referral patterns. a In an oncologist-based referral model, the patient might be directed to different services and, thus, receive variable care, depending on the palliative-care expertise and referral preferences of their oncologist, as well as local supportive care resource availability. b Automatic referral models streamline access to palliative care and help to standardized care through the use of routine screening and the implementation of automatic triggers for referral. The criteria for referral need to be tailored to achieve a balance between local palliative care resource availability and patient care needs.