Key Elements in the 'Palliative Care Syringe' Identified

Roxanne Nelson, BSN, RN

October 31, 2017

SAN DIEGO, California ― Palliative care that is integrated early into the oncology care regimen improves quality of life (QOL), mood, and the delivery of end-of-life care for patients with advanced cancer. However, it has been unclear which specific elements of palliative care practice are associated with these beneficial outcomes.

Now come the results of the first known study to address this subject. The study was presented here at the Palliative Care in Oncology Symposium (PCOS) 2017.

The investigators report that the consistent hallmarks of palliative care are addressing coping skills, which may improve QOL and depression, and managing symptoms, which is tailored to unique patient needs.

"People commonly ask, 'What is it in the palliative care syringe? What is it that we actually do?" said lead author Michael Hoerger, PhD, an assistant professor of psychology, psychiatry, and oncology at Tulane University School of Medicine and the Tulane Cancer Center, New Orleans, Louisiana.

To answer those questions, Dr Hoerger and his colleagues conducted a study that aimed to determine the key elements of early palliative care across the illness trajectory.

The cohort included 171 patients with incurable lung or noncolorectal gastrointestinal cancer who received early palliative care integrated with standard oncology care. Patients completed measures of quality of life (Functional Assessment of Cancer Therapy–General [FACT-G]) and mood (the Hospital Anxiety and Depression Scale [HADS] and the Patient Health Questionnaire–9 [PHQ-9]) at baseline and at 24 weeks.

In addition, palliative care clinicians completed electronic post-visit surveys that documented the content of each visit. The authors assessed when the visit covered key content areas (rapport, symptom management, coping), and they examined variations in visit content over time.

A total of 2921 visits took place. The typical patient experienced at least 17 visits, and most patients had more than three visits.

The average time per visit was about half an hour. Of the total cohort, 83% were outpatients, and 10% were inpatients (10%). Seven percent of the patients participated in in-depth telephone visits (7%).

Oncologists attended 23% of the visits and attended at least one visit for 84% of the patients.

"Over time, palliative care visits were consistently focused on symptom management and helping patients cope with life-threatening disease," said Dr Hoerger.

Rapport was another important element and was particularly helpful at the beginning of the palliative care regimen. Dr Hoerger pointed out that 100% of clinicians reported that they focused their time on establishing rapport during the initial visit. As rapport was established, it became less important over time.

Understanding of illness was also an important element. Although the importance of understanding illness was steady over time, less attention was paid to it than with coping with illness.

"Then the more 'difficult' topics, such as treatment decisions, advance care planning, and discharge disposition, got less focus than other topics but received more attention during the patient's final three visits," he said.

Most visits were focused on coping (64.2%) and symptom management (74.5%). At 24 weeks, patients for whom a higher percentage of visits were focused on coping experienced an improvement in QOL (FACT-G QOL: B = .19, P = .02), and depression (PHQ-9 Depression: B = -.22; = .004; HADS Depression: B = -.26, P = .002; PHQ-9: P = .005).

Interestingly, symptom management was associated with worsening in QOL, depression, and anxiety during this period (FACT-G QOL: B = .-19, P = .02; PHQ Depression: B = .20, P = .01; HADS Anxiety: B = .17, P = .02). "We would hope that focusing on symptom management would lead to some discernible improvements in outcomes, but this is more consistent with clinicians attending more to symptoms among patients experiencing declines," Dr Hoerger explained.

In cases in which a higher percentage of visits focused on treatment decisions, there was a reduction in the odds of patients receiving new chemotherapy (OR =.56, P = .02), undergoing hospitalization (OR = .62, P = .001), or being admitted to the emergency department ( P = .04) in the 60 days prior to death.

Advance care planning was associated with increased odds of receiving hospice care (OR, 1.85, P = .02) and of death at home (OR, 1.35, P = .04). "This association was also consistent with the hypothesis that clinicians may promote comfort at death through advance care planning," Dr Hoerger noted.

The Individual Patient

In a discussion of the study, Keith M. Swetz, MD, an associate professor of medicine at the University of Alabama and section chief of palliative care, Birmingham VA Medical Center, noted that this study sought to gain a clear understanding of what palliative care is and how it works.

The authors identified what they saw as key elements that are essential to good palliative care, he noted.

"But what makes a successful palliative care intervention may or may not include those interventions," Dr Swetz said. "It really comes down to the patient, and while we are looking for some consistency, we are dealing with individual patients with individual needs.

"We want to make sure that we address their needs and give them the opportunity to have those needs met," he added.

Dr Swetz also pointed out that it is necessary to identify goals of care. "What may be needed for one patient may not be helpful for another, and not effective," he said. "We really need a clear understanding of what their goals are in order to design patient-centered care."

A Louisiana clinical and translational science visiting scholar grant was funded by the National Institute of Nursing Research and the National Institute of General Medical Sciences. Dr Hoerger and Dr Swetz have disclosed no relevant financial relationships.

Palliative Care in Oncology Symposium (PCOS) 2017. Abstract 154, presented October 27, 2017.

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