COMMENTARY

Overcoming Territoriality in Palliative Cancer Care

H. Jack West, MD

Disclosures

January 21, 2020

Recently I received a call from a radiation oncologist about a patient with metastatic lung cancer whom I referred for palliative radiation of a painful bone metastasis. My colleague reported that the patient was doing poorly, with worse dyspnea and significant overall clinical decline.

We agreed to admit him, and the hospitalist asked about summoning the inpatient palliative care team. I agreed, as I had spoken with the patient and his wife about this potential transition to focus exclusively on his comfort. By the time I was able to visit the patient, he and his family had met with the palliative care team and were inclined to pursue hospice, an optimal path given his accelerated clinical deterioration.

This experience illustrates an emerging trend in our field: While medical oncologists are widely recognized as the "quarterbacks" of cancer care, the multidisciplinary team members who provide end-of-life care range from radiation oncologists and hospitalists to palliative care specialists and even emergency medicine physicians. So who should introduce these discussions and when? That question can spark territorial feelings and heated debate.

Why Some Resist Ceding End-of-Life Care to Colleagues

Gross and colleagues conducted focus groups in which they asked medical oncologists about their views on radiation oncologists discussing end-of-life care. Although they expected medical oncologists to welcome additional support, that is not what they found. Instead, the 31 primarily academic (94%) and relatively junior medical oncologists (74% in their first 5 years after completing fellowship training) were overwhelmingly negative. Their feedback had a few recurring themes:

  • Radiation oncologists typically have a limited, "problem-based" focus.

  • Radiation oncologists lack interest and expertise to deliver good end-of-life care.

  • End-of-life care for patients with cancer is the domain of medical oncologists.

  • Radiation oncologists who veer "out of their lane" may expect fewer referrals in the future.

Medical oncologists such as myself might be tempted to dismiss these findings as unrepresentative of a broader population. However, my experience over years of caring for cancer patients with an array of colleagues supports them: Too many medical oncologists are territorial about end-of-life care being our singular domain.

Cancer Care Is Changing, but Are Oncologists Changing With It?

Although large cancer programs have increasingly begun to integrate palliative care teams, their adoption has been variable and not without barriers. Several of my colleagues have been reluctant to cede control of end-of-life discussions to inpatient or outpatient teams. Yet the hospitalist may be the one left vulnerable if a patient on the brink of clinical decline has not discussed goals of care and established realistic expectations.

In fact, available evidence shows that oncologists do not address goals of care proactively or particularly well either, which can diminish end-of-life care. In a pivotal paper, Temel and colleagues studied patients with advanced non–small cell lung cancer who were randomly assigned to standard oncologic care with or without early palliative care. Patients receiving early palliative care experienced improved quality of life, including a longer median duration of hospice care (11 days vs 4 days, respectively).

Although there is undeniable value to a longitudinal patient-oncologist relationship, it's also possible that oncologists become too invested to remain objective about the appropriate time to discuss goals of care.

The way we practice medicine is changing, with a trend toward team-based care rather than an individual approach. Hospitalists increasingly manage inpatient care, palliative care programs are becoming more widely incorporated, and other specialists may feel more inclined to shape the trajectory of patients they share with medical oncologists. The boundaries that partitioned individual roles are shifting as we transition from a "man-to-man" to "zone" defense.

Our shared goal should be to provide the best care for the patient. Oncologists have historically been called upon to serve as the primary specialists to oversee palliative care for patients with cancer, but we should acknowledge that there is a growing number of caregivers to help.

H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, California, regularly comments on lung cancer for Medscape. Dr West leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.

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