Roadmap to Palliative Care Published by Groundbreaking Docs

Fran Lowry

January 31, 2013

Palliative care clinicians who are thinking of developing early or outpatient palliative care services for patients with newly diagnosed advanced illnesses might want to turn their attention to a study published online January 28 in JAMA Internal Medicine.

The study, by Jennifer S. Temel, MD, from the Massachusetts General Hospital in Boston, and colleagues, sheds light on key elements of the emerging practice of early ambulatory palliative care.

Dr. Temel and some of her coauthors were involved in a groundbreaking study of palliative care published 3 years ago (N Engl J Med. 2010;363;733-742). They found that, in addition to standard oncologic care, introducing palliative care at diagnosis led to a significant improvement in survival in patients with metastatic nonsmall-cell lung cancer. The study was called paradigm-shifting and precedent-setting by experts in palliative medicine, as reported at the time by Medscape Medical News.

The new study outlines how palliative care specialists focus on psychosocial issues and building relationships with patients and their families, whereas oncologists focus on cancer treatment and the management of medical complications.

"This study gives us a preliminary understanding of the essential aspects of palliative care that lead to the wide range of improvements in our initial study," Dr. Temel told Medscape Medical News.

"Facing a serious diagnosis like lung cancer is incredibly difficult. Much of palliative care is focused on helping patients and families cope with their illness and prognosis, which is such an important area of support and care," Dr. Temel explained. This study demonstrates that the role of palliative care is distinct from that of oncology, and that the 2 are complementary.

In the new study, Dr. Temel and colleagues analyzed what palliative care clinicians and oncologists recorded on the charts of 20 patients who received early palliative care and survived for less than 3 months (n = 5), 3 to 6 months (n = 5), 6 to 12 months (n = 5), and 12 to 24 months (n = 5).

Initially, palliative care clinicians focused on establishing relationships with patients and determining their individual needs and preferences for information early in the illness.

The researchers identified some major themes of the early palliative care visits: relationship and rapport building, addressing symptoms, addressing coping, establishing illness understanding, discussing cancer treatments, end-of-life planning, and engaging family members.

During later visits, palliative care clinicians discussed patient preferences for resuscitation and hospice care.

In contrast, oncologists focused on discussing ongoing cancer treatment and managing medical complications associated with radiographic progression or worsening of disease.

"Interestingly, discussions about end-of-life care occurred later in the course of the patient's illness," Dr. Temel noted. "So while some providers and patients still fear that palliative care will focus only on 'death and dying' or that it is synonymous with hospice care, our study confirms that palliative care focuses on supporting patients and families as they navigate their diagnosis, and is not merely focused on end-of-life care."

She added that she hopes this study "can serve as a roadmap or guide for palliative care clinicians who are developing outpatient services for patients with newly diagnosed advanced cancer or other illnesses."

The benefits of palliative care are such that all internists should seek some supplemental training, Alexander K. Smith, MD, from the University of California, San Francisco, writes in an invited commentary.

"Many patients with serious illness will probably not have access to an outpatient [palliative care] clinician, but they will probably have access to an internist," Dr. Smith explains. "Patients might benefit if all internists incorporated this approach, seeking supplementary training in [palliative care]. And some benefits, like survival, might be surprising."

He told Medscape Medical News that palliative care is an art and relationship-centered profession.

"That is a message that all doctors could learn from. When people are diagnosed with serious illness, it's important to first focus on building a strong relationship. That way, when things get tough, you have that relationship to help people get through the difficult times," he said.

This study was funded by an American Society of Clinical Oncology Conquer Cancer Foundation Career Development Award. Dr. Temel and Dr. Smith have disclosed no relevant financial relationships.

JAMA Intern Med. Published online January 28, 2013. Abstract, Commentary