Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care

Abstract

Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state-of-the-science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team-based, timely, and targeted palliative care. Team-based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse-led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00-00. 2018 American Cancer Society, Inc.

Keywords: access; delivery of health care; integration; neoplasms; palliative care.

Figure 1.. Multidimensional Supportive Care Needs.

A patient’s supportive care needs can be classified as physical, emotional, spiritual, social and informational, which are often closely associated with each other. For example, depression can contribute to poor appetite and decreased function, and the reverse could be true. Depression may also impact a patient’s decision making, their spiritual well being, and relationship with caregivers. This diagram highlights the interconnectedness of supportive care issues, and the need for multidimensional assessments and interventions with an interdisciplinary team.

Figure 2.. Interdisciplinary Palliative Care Team.

One of the most unique aspects of palliative care is the interdisciplinary nature, with different members of the team providing different expertise, thus allowing a patient’s needs to be addressed in a holistic and timely fashion, and augmenting the family caregiver(s) ability to support the patient. Other advantages of an interdisciplinary team include enhanced patient-clinician communication and shared responsibility, work load, decision making, leadership and stresses while providing care for distressed patients.

Figure 3.. Conceptual Framework on How Timely Palliative Care can Impact Patient Outcomes.

This conceptual model highlights that there may be multiple mechanisms by which palliative care can improve each outcome. An anticipatory approach to symptom management would allow patients to reduce their symptom burden related to cancer or cancer treatments, minimize symptom crises, and potentially tolerate cancer treatments better. These, in turn, may help to improve quality of life and quality of end-of-life care (e.g. avoiding emergency room visits). Longitudinal psychosocial support can improve emotional and spiritual well-being, which have also been shown to be associated with patient outcomes downstream. Enhanced communication over time may also assist palliative care teams to improve illness understanding and facilitate advance care planning, which could allow patients to minimize aggressive end-of-life care. It remains unclear if palliative care can have a survival benefit. Some investigators have postulated that a survival benefit from palliative care may be related to better management of depression, although palliative care may also improve survival by providing good symptom control and reducing intensive care at the end-of-life that could sometimes be detrimental to survival.

Figure 4.. Palliative Care is Preventative Care.

By seeing patients in a timely fashion, anticipating care needs, and providing effective interventions through education and longitudinal monitoring, the palliative care team can potentially prevent symptom crises, avoidable hospitalizations, information gaps, and catastrophes at the end-of-life (e.g. intubation at an intensive care unit).

Figure 5.. Timing for Outpatient Palliative Care Referral.

In a Delphi study, a panel of 60 international experts were asked to rate the timing of outpatient palliative care referral for patients with advanced cancer from “much too early” to “much too late”. Consensus was defined a priori at 70% or greater. The items that reached consensus are shown on the right. Permission to reprint obtained from copyright.com.

Figure 6.. Standardizing Referral to Palliative Care.

(A) Universal referral to palliative care based on prognosis is supported by randomized control trials; however, this could result in overwhelming number of patients being referred, some of whom may not require palliative care; (B) Selective referral is currently the standard practice, with the oncologist deciding if the patient would require a referral. Because there is much variability in the attitudes and beliefs of oncologists toward palliative care, referral is inconsistent and often delayed; (C) Palliative care referral based on standardized need-based criteria coupled with systematic needs assessment would allow timely identification of patients in need, and trigger referral to supportive care. This more targeted approach would allow the right individuals to be referred to palliative care at the right time, allowing the scarce resource to be used most efficiently.

Figure 7.. Primary, Secondary and Tertiary Palliative Care.

Primary palliative care is basic palliative care provided by the oncology team and primary care physicians; secondary palliative care involves specialist palliative care teams working as consultants to address the more complex supportive care needs. Tertiary palliative care involves palliative care being the attending team providing intensive supportive care for the most complex patients, such as in an acute palliative care unit.