Early intervention utilizing a team approach is important to successful palliative care, agreed a multidisciplinary panel convened at the 2016 National Comprehensive Cancer Network (NCCN) annual conference.
The panel offered insight into the value of palliative care in the cancer care continuum, emphasizing the importance of open, continuous dialogue.
The transition from active treatment to palliative care can be challenging, because patients may misperceive palliative care as “giving up,” panel members noted, and palliative care planning is difficult to achieve in the typical time allotted to patient appointments.
The roundtable opened with a personal anecdote from Shirin Malekpour, PhD, Family Member Advocate, University of Wisconsin-Madison, who described her mother’s experience with palliative care after being diagnosed with stage III ovarian cancer. “Her medical team was underprepared for our needs in palliative care issues. We were never offered palliative care, or any of the other resources but chemotherapy,” Dr Malekpour said. “Here is another surgery, and so forth.”
If not for Dr Malekpour’s husband, a hematologist at the same hospital where her mother was being treated and who knew of the available resources, palliative care would have gone unnoticed. Through him, Dr Malekpour was able to connect with Toby C. Campbell, MD, Chief, Palliative Care program, University of Wisconsin School of Medicine and Public Health, Madison, and his team. They worked with Dr Malekpour’s family to identify her mother’s priorities and end-of-life values.
Dr Campbell advised that palliative care be practiced on 3 levels:
Sophia K. Smith, PhD, MSW, Department of Nursing, Duke Cancer Institute, Durham, NC, described palliative care work at her institution. Duke is developing and testing a program called “Four Conversations.” “It is an educational curriculum around shared decision-making,” Dr Smith said. The program hopes the conversations will clarify a patient’s personal values and promote solution-focused thinking. A 2-year study of the program is being funded together by the NCCN and Pfizer.
The Four Conversations program represents:
“Patients are able to get together with their peers in a confidential online format,” said Dr Smith. The program has evolved from a face-to-face format to online to make it more accessible and cost-effective.
The program was developed for patients with metastatic breast cancer who are receiving end-of-life care to enhance quality of life and the relationship with the care team, including family members. Mind–body exercises and relaxation training are taught to patients, and patients are encouraged to complete advance directives.
“We found that only 15% of our patients who died within the past 2 years had documented directives,” Dr Smith said.
A barrier to palliative care planning is the current shortage of palliative care specialists, because clinics are only now building palliative care programs. The traditional model of referral “has not worked particularly well,” said Dr Campbell, with no-show rates of approximately 50%, making scheduling difficult.
“The next move has been toward integrated, or embedded, palliative care,” which places palliative care providers with oncology providers, he said. Home-based palliative care may be the next generation of palliative care, Dr Campbell believes.
“The team approach to [palliative] care is not a substitution, it is an addition” to the care already being provided in a clinic, said Maria Dans, MD, Clinical Director, Palliative Care Services, Siteman Cancer Center at Barnes-Jewish Hospital, St Louis, MO.