Proper care choices for patients with advanced cancers remains an open question in the oncology community. Despite limited life expectancies, patients whose diseases have reached advanced states often continue to receive aggressive therapies, which can negatively affect quality-of-life without offering therapeutic benefits.1 Although research has shown that patients with terminal cancer would prefer to die at home2, as many as 50% of cancer patients die while hospitalized, according to The National Council for Palliative Care.3
It has been suggested that a greater and more consistent integration of palliative care practices within the oncology sphere could improve outcomes across the spectrum for dying patients. Kumar and colleagues found that referral to hospice services resulted in improved symptom burdens and end-of-life care, as well as a greater attainment of patient goals.4 Similarly, the availability of palliative care has been linked to reductions in depression and feelings of burden among surviving caregivers.5
Researchers at Mount Sinai’s Icahn School of Medicine (New York, NY) recently developed standardized criteria for the integration of palliative service into their hospital’s regular solid tumor oncology service.6 Results from an interventional study published in Journal of Oncology Practice found that 80% of patients received a palliative care consultation following implementation, which contributed to significant increases in hospice referrals, and decreases in 30-day readmissions rates and chemotherapy receipt postdischarge. Mount Sinai has permanently adopted these palliative care practices in the wake of this study.
Journal of Clinical Pathways recently spoke with Kerin B Adelson, MD, assistant professor of medicine (medical oncology) at Yale School of Medicine (New Haven, CT), about how palliative services can improve patient care and reduce wasteful medical expenditures in oncology. Dr Adelson served as the lead investigator on the palliative oncology study, during which time she was employed by Icahn School of Medicine. She offered perspectives that oncologists and physicians can use to recognize which patients will most benefit from palliative services vs continued aggressive treatment.
Your study showed that palliative care is perhaps not being deployed as often in oncology as it should be. Why do you think that is?
Soon after we planned this study, the American Society for Clinical Oncology released guidelines7 for early integration of palliative care for patients with advanced cancer, based on numerous studies which showed receipt of nonbeneficial interventions at the end of life are associated with worsened patient and caregiver experiences, as well as higher costs. There are many reasons why integration of palliative care principles have not been part of general practice, and why this guideline was needed. Most practicing oncologists have not received formal training in conducting goals of care conversations. They worry about causing patients distress, or that something they say will cause a patient to give up hope. The payment system has rewarded chemotherapy administration. Furthermore, the orientation of most oncologists is to treat cancer and prolong life. Although studies show that additional treatment lines may cause more harm than good for patients with incurable cancer, it is difficult for many oncologists to shift gears and explain to patients why further treatment is unlikely to help them.
Shortly before our study was published, another study appeared in Journal of Oncology Practice8 which showed oncologists spend very little time discussing prognosis and goals with patients—instead, they are more likely to move quickly into talking about treatment. Partnering with palliative care specialists can help initiate goals of care conversations earlier, to empathically address prognosis, and to allow patients to articulate how they want to spend their remaining time.
Ideally, every oncologist would be able to provide primary palliative care while still giving disease modifying treatments. But due to the barriers already mentioned, this frequently does not occur. A promising alternative would be for patients to develop relationships with palliative care providers while continuing to undergo cancer treatments. When the time comes, it may then be easier to Segway from disease modifying treatments to palliative care.
What criteria did you use to design the study?
We wanted to capture the largest population of patients who would benefit from palliative care, so we reviewed the literature and talked to experts in both palliative care and oncology. We then developed general guidelines to identify the patients at greatest need. Ultimately, it came down to anyone with stage IV disease; any patient with acute symptomatology; any patient readmitted within 30 days; and any patient who had been hospitalized for more than 7 days. Readmission and prolonged hospitalization are markers for potential suffering and lack of clarity regarding treatment goals. We were also aware that there were going to be some patients who would be discharged to a subacute rehab center in the hopes that they would become stronger in order to receive more treatment. We wanted to keep an eye on that, because that might not be in line with the reality of the disease.
We ended up capturing about 60% of our inpatient solid tumor service. The kinds of patients who were not included were those admitted for routine chemotherapy, for laboratory abnormalities, or for procedures.
And based on those experiences, what did you find?
Because the intervention mandated that any patient who met one of the criteria would receive an immediate palliative care consultation, we saw tremendous increases in the numbers of patients visited by the palliative care service. Consultations included symptom management, discussion of care goals, and help with discharge planning. The consultation rate rose from 39% in our baseline group to 80% in our intervention group. We did not reach 100%, because consultations did not occur on weekends. We significantly increased hospice referrals, increased the support system after discharge, and reduced both 30-day readmissions and chemotherapy receipt following discharge. We considered positive discharge support to be going home with services, going home with hospice, or going to inpatient hospice. Subacute rehab admission was considered a negative discharge measure, because in this population, it is not aligned with prognosis.
The decrease in chemotherapy use following discharge is a marker for improved prognostic understanding among patients who received palliative care consultation. Chemotherapy during the last 14 days of life is a National Quality Forum–endorsed measure, and high percentages of chemotherapy receipt reflect a pattern of poor end-of-life planning. Although tracking chemotherapy within 14 days of death will raise awareness about overutilization at the very end of life, I believe we would see a greater impact if the measure focused on the 30 days preceding death—a time when helping patients identify their goals will significantly impact the quality of their end-of-life care, reduce utilization of unwanted services, and reduce overall costs. We know that patients on the inpatient solid tumor service generally have a very short life expectancy, with a median survival of about 3 months. Thus, the reduction we saw in chemotherapy following discharge suggests that our intervention helped patients identify their goals and pursue care that focused on quality of life.
So these measures have the potential to improve quality of life at the end of life?
Our study did not measure quality of life, but hospice referral has been show to improve quality of life. So if we are increasing hospice rates, it stands to reason that we are increasing quality of life as well. Receipt of chemotherapy at the end of life has been shown to greatly reduce quality of life, as was shown in a recent study by Prigerson and colleagues.9 So again, reducing that can extrapolate an improvement in quality of life.
These practices are now standard of care at Mount Sinai. Are they applicable across the spectrum?
Absolutely. The criteria work very well and are easy to employ. At Mount Sinai now, the oncology unit has a dedicated palliative care team who review the inpatient service every day, and any patient who meets criteria automatically receives a visit. It has been very successful. At Smilow Cancer Hospital, which is the clinical arm of the Yale Cancer Center, we are expanding our palliative care staffing so that we are able to offer the same approach.
What do you see as the next steps in palliative care integration research?
Although this intervention significantly improved multiple measures, it occurred in the inpatient population exclusively, which generally represents a population nearing the end of life. To maximally align care with patient preferences across the spectrum, thos conversations need to start prior to hospitalization. My colleagues and I currently have a grant from the Patient Centered Outcomes Research Institute to study how to move goals of care conversations into the earlier part of the disease trajectory, while the patient is still being treated in the outpatient setting. We are currently testing the feasibility of this in four disparate settings, including a public city hospital; an academic tertiary care hospital; an urban community hospital; and one of the rural community practices associated with Yale Cancer Center. In this randomized clinical trial, oncologists are randomly assigned to go through coaching in their own practice, with their own patients, alongside a palliative care doctor trained in goals of care communications—or to continue practicing as they normally would. We have just completed enrollment for this study, which will measure whether patients perceive that their goals were adequately addressed and whether the treatment they received was in line with their preferences. We will also look at downstream health care utilization—including whether patients whose oncologists were randomized to the coaching arm are less likely to be admitted to the intensive care unit, have fewer readmissions, and receive less chemotherapy at the end of life.
References
1. Earle CC, Landrum MD, Souza M, et al. Influence of patient preferences and local health system characteristics near the end of life: Is it a quality-of-care issue? J Clin Oncol. 2008;26(23):3860-3866.
2. Bruera E, Sweeney C, Russell N, Willey JS, Palmer JL. Place of death of Houston area residents with cancer over a two-year period. J Pain Symptom Manage. 2003;26(1):637-643.
3. Hospital remains most common place of death for cancer patients in England. The National Council for Palliative Care website. https://www.ncpc.org.uk/news/hospital-remains-most-common-place-death-cancer-patients-england. Published March 28, 2013. Accessed April 25, 2017.
4. Kumar P, Wright AA, Hatfield LA, Temel JS, Keating NL. Family perspectives on hospice care experiences of patients with cancer. J Clin Oncol. 2017;35(4):432-439.
5. Given B, Wyatt G, Given C, et al. Burden and depression among caregivers of patients with cancer at the end of life. Oncol Nurs Forum. 2004;31(6):1105-1117.
6. Adelson K, Paris J, Horton JR, et al. Standardized criteria for palliative care consultation on a solid tumor oncology service reduces downstream health care use [published online March 17, 2017]. J Oncol Pract. doi:10.1200/JOP.2016.016808
7. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology practice guideline update. J Clin Oncol. 2017;35(1):96-112.
8. Singh S, Cortez D, Maynard D, Cleary JF, DuBenske L, Campbell TC. Characterizing the nature of scan results discussions: Insights into why patients misunderstand their prognosis. J Oncol Pract. 2017;13(3):e231-e239.
9. Prigerson HG, Bao Y, Shah MA, et al. Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol. 2015;203(8):569-573
