Improve Patient Outcomes with Early Palliative Care

Palliative care, hospice care, and end-of-life care are an important part of all hematology/oncology practices. Although anticancer therapy is frequently initiated with a cure in mind, there are many clinical situations where a cure is not possible. In that case, a palliative care approach is an important next step. However, there is often poor awareness and misperceptions of palliative care and hospice, which can deter patients from seeking palliative care services.There are several studies and registries that demonstrate the benefits of early introduction of palliative care as a complementary approach to traditional anticancer therapies.

Key areas to address when discussing palliative care and hospice with our patients include:

• Information on their cancer

• Patient/family perception of risks and benefits of the treatments

• Communication of prognosis

• Defining goals of treatment

• Advanced care planning and preferred place of death

• Involvement of relatives

• Reducing caregiver burden

There are also benefits at the practice/institutional level:

• Early initiation of palliative care to decrease ineffective treatments

• Defining goals of care and end-of-life care

• Communication improvements for the family/patient/care team

• Decreasing testing and transfusion use when not indicated

• Defining the accepted use of antimicrobial treatments during end-of-life care

Odejide and colleagues asked a national cohort of oncologists in the US about barriers to accessing quality end-of-life care for their patients.1 The most frequently mentioned barriers were unrealistic patient/family expectations about disease prognosis, including treatment options and outcomes (97.3%), clinicians’ concerns about taking away hope from patients (71.3%), and unrealistic physician expectations about disease prognosis (59%).

This approach of being open, honest, and having a balanced discussion with our patients and families about their prognosis and the chances of successful anticancer therapy is especially important to the physician-patient and physician-family relationship. The early introduction of palliative care discussions is very beneficial rather than waiting until there is a medical crisis. Although patients with advanced solid tumors often have early introduction of palliative care, patients with hematologic malignancies often have delayed referrals. The barriers for delayed referrals include the initial goal of a cure, the inability to administer transfusions while in hospice, and patient/family expectations. Despite ongoing education, it is not infrequent that patients’ views of their prognosis remain discordant with their physicians’.

To facilitate the integration of palliative care, best practice is for institutions/physicians to standardize pathways for early involvement of palliative care (inpatient and outpatient), strengthen communication skills of health care providers, and establish standardized practices for end-of-life care, transfusions, and antimicrobial treatments. In some practices/institutions, it is a standard of care to introduce palliative care services for any patient with an advanced-stage malignancy soon after the time of diagnosis. Using this method of early introduction of palliative care services will allow for an easy transition to hospice services when the appropriate time comes for those services. Hopefully, standardization will improve the pathway for the patient, the family, and the health care system.

Odejide OO, Cronin AM, Condron NB, et al:Barriers to quality end-of-life care for patients with blood cancers.J Clini Oncol. 2016;34(26): 3126-3132. doi:10.1200/JCO.2016.67.8177