A New Model of Palliative Care for Oncology Patients with Advanced Disease

Polly Mazanec, PhD, ACNP-BC, AOCN; Barbara J. Daly, PhD, RN, FAAN; Elizabeth F. Pitorak, MSN, FPCN; Donna Kane, MSN; Sally Wile, MDiv; Judith Wolen, MSW, LISW-S

Disclosures

Journal of Hospice and Palliative Nursing. 2009;11(6):324-331. 

In This Article

Abstract and Introduction

Abstract

Advances in oncology treatment have prompted the need for a new model of palliative care. The Cancer Support Team, formerly known as the Safe Conduct Team, of the Ireland Cancer Center practices under a new model that emphasizes the variable timing of palliative care needs of patients and families across the cancer disease trajectory. This new model assumes that palliative care is offered in conjunction and as a component of disease-oriented care, but unlike previous models, it does not follow a linear pattern of use. Care needs fluctuate throughout the course of life-limiting disease. In addition, this new model recognizes that as current cancer treatment options improve quantity and quality of life, patient goals of care often include appropriate disease-oriented treatment near the end of life, prohibiting enrollment in hospice based on Medicare regulations. This model of palliative care ensures that oncology patients and families will receive an interdisciplinary plan of care based on their goals and preferences, even if they do not choose hospice care or do not qualify for the hospice benefit.

Introduction

Access to expert end-of-life (EOL) care is critical for patients and their families living with life-limiting illnesses. Many choose hospice for its support, expertise, and team resources, but many do not. The National Hospice and Palliative Care Organization's (NHPCO) most recent statistics estimate that 1.3 million patients received hospice services in 2006, and this was a 162% increase since 1996. However, only 36% of all who died in the United States in 2006 had the care of a hospice program.[1] The average length of stay and median length of stay were 59 and 20.6 days, respectively. Many of those dying with hospice care have access to these services for fewer than 3 weeks, hardly enough time to benefit from the expertise of the hospice team. There is a need to improve access to care by expanding the Medicare Hospice Benefit for those who want hospice and are receiving disease-oriented interventions.[2] For those who do not choose hospice, there is a need to provide access to palliative care programs that offer quality care, especially at the end of life.

In response to the need for better care for dealing with life-threatening illnesses, programs are being developed across the country to provide aggressive supportive care through palliative care consultant services, palliative care hospital-based teams, and integrated palliative care teams that provide services across the disease trajectory. The World Health Organization[3] and the National Consensus Project for Quality Palliative Care[4] recommend that palliative care be provided from the time of diagnosis of a life-limiting disease until death.

Consistent with these recommendations, the Cancer Support Team (CST; formerly known as the Safe Conduct Team) of the Ireland Cancer Center (ICC), University Hospitals of Cleveland, has provided palliative care to patients and families facing advanced lung and gastrointestinal (GI) cancers from patient diagnosis through family bereavement. In this article, we describe the transition to a modified model of palliative care, better suited to the challenges of caring for patients with advanced cancer at a comprehensive cancer center. This model emphasizes the importance of providing collaborative care that is based on patient and family goals and appropriate medical intervention. It serves as the framework for seamless care regardless of the patient's decision for disease-oriented treatment and/or palliative care. It provides a model of care for those who choose hospice and for those who do not.

The new model for disease-oriented palliative care aims to provide comprehensive, tailored palliative care throughout the cancer disease trajectory. This model recognizes that palliative care is offered in conjunction with, and as a component of, disease-oriented care and, unlike more current models of palliative care, does not follow a linear pattern of usage. It recognizes that the need for palliative care fluctuates over the course of the disease and is based on complex, individualized needs and goals of care.

Many individuals prefer to continue disease-oriented care until the time of death. The current Medicare Hospice Benefit is not designed to accommodate this goal. The new model of palliative care focuses on patients' and families' goals of care and enables patients to receive expert palliative care without having to forgo disease-oriented treatment that is considered aggressive according to the hospice Medicare regulations and current hospice philosophy.

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