A new guidance statement from the American Society of Clinical Oncology (ASCO) and the American Academy of Hospice and Palliative Medicine (AAHPM) provides the first formal, consensus-based recommendations regarding high-quality primary palliative care in oncology, according to Kathleen E. Bickel, MD, MPhil, Assistant Professor of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH. The statement could potentially standardize primary palliative care delivery across oncology settings. Dr Bickel participated in the panel that developed the guidance statement and presented its goals at the 2015 Palliative Care in Oncology Symposium.
When integrated into routine oncology care, palliative care improves symptom burden, quality of life, and patient and caregiver satisfaction. However, not all patients with cancer have access to specialist palliative medicine. “For the first time, we’ve set some reasonable and achievable goals for high-quality primary palliative care delivery for oncology practices in the everyday care of patients, which we hope will improve patient comfort and quality of life,” said Dr Bickel.
“Serious illness is hard, and there’s a lot we want our medical team to do for us,” said Dr Bickel. “This guidance statement is intended to represent what oncology clinic stakeholders feel right now is reasonable, important, and feasible to implement in current practice.”
According to her, consistent access to at least basic palliative care services would be improved if the delivery of high-quality primary palliative care services were incorporated in all medical oncology practices. Therefore, investigators sought to determine which palliative care elements constitute high-quality palliative care delivery in US medical oncology practices, for adult patients with advanced cancer or high symptom burden.
Palliative Care Domains for Oncology Practices
In developing the guidance statement, the investigators focused on what could be delivered solely by oncology practices versus what should be delivered by palliative care specialists. “The purpose of this project is to give oncology practice real tools to improve their delivery of primary palliative care,” said Dr Bickel.
An expert steering group of committee members from AAHPM and ASCO developed a list of 966 potential palliative care service items, which were divided into 9 domains of palliative care categories relevant to oncology practice. Each of the domains reflects an aspect of palliative care delivery for patients with advanced cancer. The 9 domains include:
- Symptom assessment and management
- Psychosocial assessment and management
- Spiritual and cultural assessment and management
- Communication and shared decision-making
- Advance care planning, including ethical and legal issues
- Coordination and continuity of care
- Appropriate palliative care and hospice referral
- Caregiver support (family/caregiver and staff)
- End-of-life care.
The items within the domains were categorized by composite ratings of “include,” “uncertain,” or “exclude.”
The panel was comprised of 22 physicians and 9 other healthcare team members, including nurses, social workers, and patient advocates. The 31 multidisciplinary panelists ranked each service item according to its importance within the oncology office—how essential the service is to the delivery of high-quality care to patients with advanced cancer; how feasible is it for a practice; and the scope of practice (how reasonable it is to expect that this service should be provided by medical oncology practices).
“Nowhere in this did we ask about the evidence or what the committees are saying,” said Dr Bickel. “This was about more of a general feeling.”
End-of-Life Care Deemed Most Important
The highest endorsement was given to palliative care services related to end-of-life care (81%), communication and shared decision-making (79%), and advance care planning (78%). The lowest proportions were for spiritual and cultural assessment and management, and psychosocial assessment and management.
Of the 966 potential palliative care service items, the consensus panel rated 598 (62%) items as deserving to be included in the scope of oncology practice, 21 services as not deserving to be included, and 347 as “uncertain.”
The list of service items may help oncology providers who wish to enhance the quality of their palliative care delivery, but “this is a guidance statement, these are not guidelines,” Dr Bickel stressed. However, metric development may be informed by the data from this consensus process.
“We’re not saying that everyone must do these things starting tomorrow, and these goals may adapt and change over time,” Dr Bickel said. “But this is what a group of real people in the trenches thought to be a reasonable starting place for oncologists to try to start doing palliative care themselves.”