New Guidelines for Primary Palliative Care in Oncology

Roxanne Nelson RN, BSN

October 08, 2015

A new guidance statement to define high-quality primary palliative care delivery in medical oncology has been developed by the American Society of Clinical Oncology (ASCO) and the American Academy of Hospice and Palliative Medicine (AAHPM).

The two organizations have partnered to develop these recommendations to help medical oncology practices identify essential palliative care services and deliver high-quality primary palliative care to all patients with cancer.

"This is an important first step to improve the palliative care that is directly delivered by oncologists," said lead study author Kathleen Bickel, MD, MPhil, an assistant professor of medicine at the White River Junction Veterans Affairs Medical Center and the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

Dr Bickel spoke during a press briefing held in advance of the 2015 Palliative Care in Oncology Symposium, which will run from October 9 to 10 in Boston, Massachusetts.

"We want to improve what we are calling primary palliative care in oncology," she commented. "We know that there is overlap between specialist palliative care and specialist oncology care."

Palliative care that is integrated in routine oncology care can improve symptom burden, quality of life, and patient and caregiver satisfaction. ASCO recommends concurrent use of palliative care with cancer care early in the course of illness for any patient with metastatic cancer and/or high symptom burden.

However. not all patients with cancer have access to experts in palliative medicine, said Dr Bickel. "The small workforce of palliative care specialists is insufficient to meet the needs of all cancer patients who might benefit from palliative care services across the US. Thus, alternative models are being sought."

Although oncologists do already provide many palliative services, until now, there has been no comprehensive guidance for what practices should provide.

Developing the Guidelines

The goal of this project was to determine which palliative care elements constitute primary palliative care delivery in US oncology practices for adult patients with advanced cancer or high symptom burden.

To develop the guidance statement, an expert steering committee developed a list of 966 palliative care service items, divided into nine domains, with each domain describing an aspect of palliative care delivery for patients with advanced cancer. Using a modified Delphi methodology, 31 multidisciplinary panelists, which included physicians, patient advocates, social workers, nurses, and nurse practitioners, ranked each service item according to importance, feasibility, and scope.

The panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%), Communication and Shared Decision Making (79%), and Care Planning (78%).

The lowest proportions were in Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%).

In the largest domain, Symptom Assessment and Management, the consensus was that all symptoms should be assessed and managed at a basic level, with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea, and pain.

Under the domain of Appropriate Palliative Care and Hospice Referral, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients with an expected survival of less than 3 months or poor performance status to hospice.

Table. Palliative Care Service Items

Palliative Care Domain Percentage of Domain Number of Items
End-of-Life Care 81% 46
Communication and Sharing Decision Making 79% 72
Advance Care Planning 78% 52
Appropriate Palliative Care & Hospice Referral 69% 29
Symptom Assessment & Management 66% 259
Caregiver Support 56% 53
Coordination/Continuity of Care 48% 23
Psychosocial Assessment & Management 39% 40
Spiritual and Cultural Assessment & Management 35% 24

"This is an important first step to improve the palliative care that is directly delivered by oncologists," said Dr Bickel. "In order to improve palliative care delivery and access for patients with cancer, we must first define and agree on what oncology practices should be providing. These goals may adapt and change over time."

In a comment on the abstract, press briefing moderator and ASCO expert Don Dizon, MD, noted that these efforts represent an important collaboration and a new concept of primary palliative care.

"These guidelines will be helpful to delineate what palliative services should be reasonably expected as part of medical oncology and what should be referred to a specialist in palliative care," added Dr Dizon, who is also clinical codirector of gynecologic oncology at Massachusetts General Hospital in Boston.

No funding source was disclosed for this study. Several of the coauthors have disclosed relationships with industry, as noted in the abstract.

2015 Palliative Care in Oncology Symposium: Abstract 108. Presented October 10, 2015.

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