Palliative Care in Oncology

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“The best care possible does not stop with excellent disease treatments; it includes concern for a person’s physical comfort, emotions and spiritual well-being.” Ira Byock, The Best Care Possible

I. INTRODUCTION. The focus of palliative care is to achieve the best possible quality of life (QOL) for patients and their caregivers at any stage of serious illness. Its hallmark is a comprehensive, team-based interdisciplinary approach, emphasizing collaboration and coordination of care with other providers and across settings. According to the most recent WHO definition, “palliative care is an approach that improves quality of life of patients and their families facing problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”

II. HISTORY OF PALLIATIVE CARE. The wider concept of palliative care began with the establishment of the hospice movement. The term “hospice” (from the same linguistic root as “hospitality”) can be traced back to medieval times when it referred to a place of shelter and rest for weary or ill travelers on a long journey. The name was first applied to specialized care for dying patients by social worker and physician Dame Cicely Saunders, who began her work with the terminally ill in 1948 and eventually went on to create the first modern hospice, the St. Christopher’s Hospice, in London in 1967.

The first American hospice opened in 1974 in New Haven, Connecticut. In 1979, the National Hospice Organization was formed in the United States, and in 1982, the Health Care Finance Administration established the Medicare Hospice Benefit (MHB). Although at its inception hospice care was most often provided at specialized facilities, today most hospice care in the United States is delivered at home. Hospice care is also available in homelike hospice residences, nursing homes, assisted living facilities, veterans’ facilities, hospitals, and prisons. However, availability of hospice care is generally limited by its payments structure (capitated payments) and eligibility criteria, which generally do not allow patients to receive hospice care alongside with disease-modifying or life-prolonging treatments.

Palliative care originated within the hospice movement and shares its philosophy as a well-care model based on interdisciplinary teams emphasizing that patient and family wishes and goals are recognized and respected. The first US hospital-based palliative care programs began in the late 1980s at a handful of institutions such as the Cleveland Clinic and Medical College of Wisconsin. Since then, there has been a marked increase in hospital-based palliative care programs—now numbering over 1,500—as well as recent developments in home-based palliative care and establishment of outpatient centers. In 2001, with the support of the Robert Wood Johnson Foundation, palliative care leaders from across the United States met to discuss the standardization of palliative care across settings with the goal of improving quality. In order to facilitate the discussion, the National Consensus Project was formed, which became a task force in 2003, under the organizational structure of the Coalition of Hospice and Palliative Care, which includes the American Academy of Hospice and Palliative Medicine (AAHPM), the Center to Advance Palliative Care (CAPC), the Hospice and Palliative Nurses Association (HPNA), and the National Palliative Care Research Center (NPCRC). Advanced Palliative Care Certification for hospitals was first offered by Joint Commission in 2011, to promote high standards in quality and adherence to published guidelines. To reflect specialized expertise and training required for the practice of palliative care, the American Board of Medical Specialties (ABMS) approved the creation of Hospice and Palliative Medicine (HPM) as a subspecialty of 10 participating boards. As a result of this approval, the first ABMS-recognized examination was administered in 2008. There are currently close to 200 HPM fellowships in the United States, and the specialty is rapidly growing. Despite this growth, many sources project severe shortages of HPM physicians in the coming years, emphasizing the need for wider education of other specialists, including oncologists, as well as primary care physicians, and midlevel providers in basic palliative care skills.

III. PALLIATIVE CARE CORE PRINCIPLES According to the National Consensus Project, the following features characterize palliative care philosophy and delivery:

A. Care is provided and services are coordinated by an interdisciplinary team consisting of physicians, nurses, social workers, chaplains, and may also include pharmacists, psychologists, physical therapists, nutritionists, as well as other support specialists to meet patient and family physical, psychosocial, and spiritual needs.

B. Patients, families, and palliative and nonpalliative providers communicate and collaborate about care needs.

C. Services are provided concurrent with or independent of curative or life-prolonging care.

D. Patients’ and families’ hopes for peace and dignity are supported through the course of illness, through the dying process, and after death.

Like hospice, palliative care aims to relieve suffering in its many forms and improve QOL, but it is applicable to a much broader patient population, including patients living with progressive, chronic conditions (i.e., AIDS, cardiovascular diseases, dementia, neurodegenerative conditions, metabolic diseases, renal or kidney dysfunction, and advanced malignancy), and acute, life-threatening illnesses or injuries (i.e., severe trauma, ICU admission, or acute leukemia) where the disease itself or its treatments pose significant challenges to the QOL and well-being of the patient and family.

IV. RATIONALE FOR ONCOLOGY PALLIATIVE CARE. Despite multiple advances in oncology in recent years and decades, patients and caregivers still shoulder significant physical, psychological, spiritual, and financial burdens while dealing with cancer and its treatments. For example, in a recent large systematic review including over 25,000 patients with incurable cancers, including solid tumors and hematologic malignancies, pain was present in 71%, gastrointestinal symptoms (nausea, vomiting, or constipation) in 20% to 37%, dyspnea in 35%, fatigue in 74%, depressed mood in 39%, and anxiety in 24% (J Pain Symptom Manage 2007;34:94). These symptoms have a significant negative effect on QOL and are associated with worsened ECOG performance status. Unfortunately, symptom management and adequate control remains a challenge, even for patients with early stage malignancies and cancer survivors. A seminal research published in a recent study of 3,123 ambulatory patients with breast, colorectal, lung, or prostate cancer revealed that 33% were still receiving inadequate analgesic treatments (J Clin Oncol 2012;30:1980). Pain rarely occurs in isolation, with most patients experiencing a variety of symptoms that tend to occur at a similar time, a phenomenon recently dubbed symptom cluster (J Pain Symptom Manage

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