Palliative Care Requires a Team Approach

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 multidisciplinary 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.

A Personal Experience

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 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.

The 3 Levels of Care

Dr Campbell advised that palliative care be practiced on 3 levels:

  1. Primary palliative care is the care provided by clinicians who do not often practice palliative care, such as primary care providers
  2. Secondary palliative care refers to the routine circumstances involved in managing seriously ill patients; this type of palliative care is integral to everyday practice in oncology
  3. Tertiary palliative care means referral to palliative care services.
Whereas oncologists discuss physical symptoms, palliative care providers tend to talk about emotional and psychological symptoms, which are issues that may be considered part of advance care planning, said Dr Campbell. “You can reassure yourselves that your patients will not be spending time going over the same stuff that they have already been over,” he added.

“Four Conversations”

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. A 2-year study of the program is being funded together by the NCCN and Pfizer.

The 4 conversations program represents (1) the patient–provider interactions, (2) the patient’s discussions with his or her loved ones, (3) the patient’s spiritual life, and (4) the patient’s discussion with self (self-care). The program provides online content and offers group-facilitated meetings led by a social worker who is trained in the curriculum.

“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.

Barriers to Palliative Care

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.

Related Articles

Subscribe to
Oncology Practice Management

Stay up to date with oncology news & updates by subscribing to recieve the free OPM print publications or weekly e‑Newsletter.

I'd like to recieve: