Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care

The Role of Specialty Palliative Care in Elective Surgical Oncology: A Systematic Review

BACKGROUND

Unlike advanced cancer populations, for whom early and routine specialty palliative care (PC) referral has demonstrated clear benefits for quality of life and symptom control, evidence supporting PC for patients undergoing curative-intent cancer surgery has been inconclusive.

METHOD

A systematic review of the PubMed, Embase, Cochrane Library, and MEDLINE databases was performed to identify all studies evaluating the role of PC for patients undergoing curative-intent surgery for cancer.

RESULTS

Among the 12,886 publications initially retrieved, 14 met all inclusion criteria: two cross-sectional studies comprised of physician surveys, four cohort studies, five qualitative studies, one prospective trial, and two randomized controlled trials (RCTs). In non-randomized studies, PC was associated with increased advanced care planning and symptom control; however, both the PERIOP-PC and SCOPE RCTs found no significant improvement in quality of life with routine perioperative PC among patients undergoing major abdominal cancer surgery. Qualitative studies characterized patient experiences and physician perspectives of PC.

CONCLUSION

This systematic review summarizes the existing literature on the role of PC in surgical oncology, highlighting the unique considerations and unmet needs of surgical patients that differ from those with advanced cancer. While the routine use of perioperative PC for patients undergoing cancer surgery is not supported, future research should focus on identifying high-risk patients who would most benefit from specialty PC and innovative methods of delivering supportive care in surgical oncology.

The communication experiences of persons referred to specialist palliative care services and their carers: A descriptive phenomenological study

OBJECTIVES

Effective communication during specialist palliative care (PC) referral is linked to improved health outcomes. Initiating a conversation about PC is difficult and poor communication can lead to stigma. The aim of this descriptive phenomenological study was to explore the communication experiences of persons referred to specialist PC services and their carers and explore strategies to improve such experiences.

METHODS

Purposive sampling was used to recruit 17 participants who were either receiving specialist PC and/or caring for someone who was receiving specialist PC. Participants were recruited from a hospice. Inductive thematic analysis was conducted.

RESULTS

Four themes were identified: (i) The why, who, what, when, where, and how of PC referral; (ii) initial thoughts and feelings about referral to PC; (iii) enhancing the communication of PC referral; and (iv) addressing practical needs during PC referral. Participants were referred either through their general practitioner or oncologist. Initially, participants linked PC referral to death. This perception changed when participants started availing of the services. Compassion, empathy, hope, privacy, in-person communication, individualized referral, and information dosing were identified as building blocks for effective communication. Participants stressed the importance of raising public awareness of PC and addressing the practical needs of individuals being referred.

SIGNIFICANCE OF RESULTS

The communication of PC referral should be tailored to meet the individual needs of patients and carers. Delivering clear and simple information is important to help patients and carers understand and accept the referral.

Primary Palliative Care in Assisted Living and Residential Care: A Metasynthesis

Assisted living (AL) and residential care (RC) settings are experiencing substantial growth as older adults with lower care needs seek alternatives to nursing homes. Despite this trend, there is a lack of skilled nursing care to support palliative care (PC) in these environments. Primary PC delivered by AL staff has emerged as a potential model to bridge this gap, focusing on symptom management and holistic support for individuals with serious illness. A metasynthesis of 88 qualitative studies was conducted to explore the provision of primary PC in AL/RC settings. The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care was used to provide a holistic framework to identify unmet PC need and gaps in PC delivery. Studies published between 2012 and 2024 were analyzed to identify themes and categories related to PC domains, including physical, psychological, social, spiritual, cultural, end-of-life care, and ethical and legal considerations. Thematic synthesis revealed key findings across the identified PC domains within AL/RC settings. Studies highlighted challenges and opportunities for delivering primary PC in these environments, emphasizing the importance of addressing physical symptoms, psychological distress, social isolation, and spiritual needs among residents with serious illnesses. The metasynthesis underscores the critical role of primary PC in enhancing quality of life and care continuity for older adults residing in AL/RC settings. It also identifies gaps in current practices and emphasizes the need for tailored interventions and training to support care providers in delivering comprehensive PC to this population. By integrating qualitative research findings with the National Consensus Project guidelines, this metasynthesis provides a comprehensive overview of primary PC in AL/RC settings. The study underscores the necessity of enhancing PC delivery in these environments to meet the evolving needs of older adults with serious illnesses, thereby improving overall quality of care for residents with unmet palliative needs.

Palliative Care as a Component of High-Value and Cost-Saving Care During Hospitalization for Metastatic Cancer

PURPOSE

Randomized controlled trials have demonstrated that palliative care (PC) can improve quality of life and survival for outpatients with advanced cancer, but there are limited population-based data on the value of inpatient PC. We assessed PC as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer and identified hospitalization characteristics significantly associated with high costs.

METHODS

Hospitalizations of patients 18 years and older with a primary diagnosis of metastatic cancer from the National Inpatient Sample from 2010 to 2019 were analyzed. We used multivariable mixed-effects logistic regression to assess medical services, patient demographics, and hospital characteristics associated with higher charges billed to insurance and hospital costs. Generalized linear mixed-effects models were used to determine cost savings associated with provision of PC.

RESULTS

Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in US dollars (USD) to $56,098 USD, whereas the median hospital cost remained stable at $14,300 USD. Receipt of inpatient PC was associated with significantly lower charges (odds ratio [OR], 0.62 [95% CI, 0.61 to 0.64]; P < .001) and costs (OR, 0.59 [95% CI, 0.58 to 0.61]; P < .001). Factors associated with high charges were receipt of invasive medical ventilation (P < .001) or systemic therapy (P < .001), Hispanic patients (P < .001), young age (18-49 years, P < .001), and for-profit hospitals (P < .001). PC provision was associated with a $1,310 USD (-13.6%, P < .001) reduction in costs per hospitalization compared with no PC, independent of the receipt of invasive care and age.

CONCLUSION

Inpatient PC is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Integration of inpatient PC may de-escalate costs incurred through low-value inpatient interventions.

Enhancing oncology patient care: nurses' knowledge, attitudes, and perceived benefits of early palliative integration - a cross-sectional study

BACKGROUND

Palliative care aims to improve quality of life for patients with end-stage illnesses by addressing physical, psychological, social and spiritual needs. Early referral to palliative care improves patient outcomes, quality of life and overall survival in a variety type of cancers. This study aimed to assess knowledge, attitudes and perceived benefits of early integration of palliative care among oncology nursing.

METHODS

A descriptive cross-sectional study was conducted in public, private, and educational hospitals located in Palestine. Data were collected using paper based self-administered questionnaires from nurses working in hematology, general oncology, and bone marrow transplantation departments.

RESULTS

Among of 128 nurses, the study revealed a moderate level of knowledge (3.64 ± 0.96), Positive attitude (3.59 ± 1.02) and moderately recognized the perceived benefits of early palliative care (3.57 ± 1.02). A statistically significant difference in nurses' knowledge, attitudes and perceived benefits of early palliative care based on clinical experience. Pearson's correlation showed a significant positive relationship between the total knowledge and attitudes score (r = 0.211, p < 0.001), as well as with perceived benefits total score (r = 0.567, p < 0.001). Moreover, there was a significant positive relationship between the total attitude score and perceived benefits score (r = 0.303, p < 0.001).

CONCLUSIONS

These findings suggest that enhancing knowledge and highlighting the benefits of early palliative care integration could foster more favorable attitudes among oncology nurses. investing in education and training to have all nurses prepared to provide high-quality palliative care results in better patient outcomes and less suffering. Patients with advanced cancer should be referred to the palliative care teams at an early stage of treatment in conjunction with their treatment in order to improve patient outcomes and quality of life.

Palliative care in the public health system: how do physicians deal with their patients at the end of life?

BACKGROUND

Patients with cancer are referred late to palliative care services (PCS).

AIM

To analyse the time of referral to PCSs and the characteristics of patients that are referred.

METHODS

A retrospective cohort. All patients admitted in a single tertiary care institution were evaluated by the PCSs from February 1, 2018 to January 31, 2019.

FINDINGS

Among the 642 patients (557 patients with cancer) referred to PCSs: 7.47% died before evaluation, 13.08% died before transfer, and 15.6% died within 8 days after transfer. Out of all the patients with cancer included in the study, 85.28% had less than 2 months of PCS follow-up during their disease. In the last 30 days of life, 96.26% had were readmitted to hospital. A total of 94.09% of patients with cancer died in a hospital.

CONCLUSION

These findings suggest that patients with cancer in Brazil are not referred early enough to PCSs. Early integration with PCS must be sought to improve the accuracy of referral.

How Other Specialists See Palliative Care Uncovering Their Deep Metaphors to Improve Our Initial Outreach Strategies

Many patients who could benefit from palliative care (PC) do not access it because of the timing and tenor of the introduction provided by their specialist. A barrier to improving specialists' (from disciplines other than PC) engagement with PC services may be an inadequate understanding of how those specialists view PC. As part of a larger project to develop public messaging for advance care planning, PC, and hospice, we conducted a qualitative market research study aimed at identifying the "deep metaphors" held by specialists about PC to provide an empirical foundation for more effective outreach and messaging. To identify deep metaphors, we used the qualitative Zaltman Metaphor Elicitation Technique to uncover thought patterns from participants' images and interview responses, revealing deeper emotional meanings and unconscious mental orientations. We enrolled 20 provider-level clinicians from a variety of professional disciplines and specialties to participate in a one-hour semi-structured interview that required prework. The interviews were videorecorded and transcribed and were analyzed along with images brought by participants using a variation of the constant comparative method. The themes included: Having to tell patients the "right" information and path; Not allowing myself to make mistakes; Depending on algorithms so I can give my patients the best care; Putting the patient in charge can challenge clinical algorithms; Observing that PC seems to lack an objectively "right" decision; Consulting PC invites subjectivity best contained at the end of the algorithm. These themes can inform strategies for outreach and messaging to other serious illness specialist clinicians to lower reluctance to consult PC, increasing patient access.

Strategies Used by Outpatient Oncology Nurses to Introduce Early Palliative Care: A Qualitative Study

BACKGROUND

Although early palliative care is linked to improved health-related quality of life, satisfaction with care, and symptom management, the clinical strategies that nurses use to actively initiate this care are unknown.

OBJECTIVES

The aims of this study were to conceptualize the clinical strategies that outpatient oncology nurses use to introduce early palliative care and to determine how these strategies align with the framework of practice.

METHODS

A constructivist-informed grounded theory study was conducted in a tertiary cancer care center in Toronto, Canada. Twenty nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) from multiple outpatient oncology clinics (ie, breast, pancreatic, hematology) completed semistructured interviews. Analysis occurred concurrently with data collection and used constant comparison until theoretical saturation was reached.

RESULTS

The overarching core category, pulling it all together , outlines the strategies used by oncology nurses to support timely palliative care referral, drawing on the coordinating, collaborating, relational, and advocacy dimensions of practice. The core category incorporated 3 subcategories: (1) catalyzing and facilitating synergy among disciplines and settings , (2) promoting and considering palliative care within patients' personal narratives , and (3) widening the focus from disease-focused treatment to living well with cancer .

CONCLUSION

Outpatient oncology nurses enact unique clinical strategies, which are aligned with the nursing framework and reflected multiple dimensions of practice, to introduce early palliative care.

IMPLICATIONS FOR PRACTICE

Our findings have clinical, educational, and policy implications for fostering the conditions in which nurses are supported to maximize their full potential in the introduction of early palliative care.

Clinician perspectives on delivering primary and specialty palliative care in community oncology practices

PURPOSE

Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities.

METHODS

Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment.

RESULTS

Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%).

CONCLUSION

Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.

Intensity of Symptoms and Perception of Quality of Life on Admission to Palliative Care: Reality of a Portuguese Team

BACKGROUND

Palliative care (PC) corresponds to an approach that enhances the quality of life for patients facing life-threatening diseases, such as cancer, as well as for their families. There are various models for providing palliative care. Early referral to PC of patients with advanced cancer has a significant positive impact on their quality of life. However, the criteria for early referral still remain controversial.

OBJECTIVES

To evaluate patients' symptomatic intensity and perception of quality of life on admission to a PC unit and to analyze these two variables according to different models of approach (outpatient and inpatient care).

METHODS

A cross-sectional, descriptive, and correlational study was conducted with a sample of 60 patients sequentially admitted to a PC unit from palliative outpatient consultations or other inpatient services in a tertiary hospital dedicated to oncology care. The evaluation protocol included a sociodemographic and medical questionnaire, the Edmonton Symptom Assessment Scale (ESAS), and the Palliative Care Outcome Scale (POS) completed by patients within the first 24 h after admission.

RESULTS

The participants were mostly male (61.7%), with a median age of 72 years. The majority of patients (n = 32; 53.3%) were undergoing outpatient treatment, while the remaining individuals (n = 28; 46.7%) were transferred from other hospital services (inpatient care). In the outpatient care group, higher scores for fatigue and dyspnea were observed. Conversely, in the inpatient care group, higher scores were observed for pain, depression, and anxiety. There were significant differences between the two groups regarding the POS dimensions of meaning of life, self-feelings, and lost time. In the inpatient group, there was a longer time between diagnosis and referral to PC; however, it was also in the inpatient group that there was less time between PC referral and first PC evaluation, between PC referral and PC unit admission, and between PC referral and death. There were no significant correlations between referral times and ESAS/POS scores in the inpatient and outpatient groups.

CONCLUSIONS

The patients admitted to the Palliative Care Unit presented a high symptom burden and changes in the perception of quality of life. However, there are no statistically significant differences between one model of approach in relation to the other. It was found that poorer symptom control and quality of life were associated with a shorter referral time for PC, because this was only initiated after curative care was suspended, particularly in our institutional context. Early referrals to the PC team are essential not only to relieve symptom-related distress but also to improve treatment outcomes and quality of life for people with cancer.

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PURPOSE

Upper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.

METHODS

We conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019-2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.

RESULTS

The total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66-75 years 0.71, IRR 76-85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1-5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).

CONCLUSION

People with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers

Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.

Prognostic value of the Scottish Inflammatory prognostic Score in patients with NSCLC expressing PD-L1 ≥ 50 % progressing on first-line pembrolizumab

BACKGROUND

Most patients with advanced non-small cell lung cancer (NSCLC) treated with first-line pembrolizumab monotherapy will experience progressive disease (PD). Only a minority will go on to receive subsequent systemic anticancer therapy for which outcomes are guarded. We investigated the prognostic significance of biomarkers of systemic inflammation following failure of first-line pembrolizumab for NSCLC to aid subsequent management decisions.

METHODS

Patients with radiological and/or clinical evidence of PD on first-line pembrolizumab for advanced NSCLC at a regional Scottish cancer centre were identified. Inflammatory biomarkers at the time of PD, including serum albumin, neutrophil count and the Scottish Inflammatory Prognostic Score (SIPS; combing albumin and neutrophils), and clinicopathological factors, including age, sex, histology, PDL1 expression and time to PD were recorded. The relationship between these and post-progression overall survival (ppOS) were examined.

RESULTS

Data were available for 211 patients. Median ppOS was 2.1 months. Only SIPS was predictive of ppOS on multivariate analysis (HR2.54 (95 %CI 1.81-3.56) (<0.001)), stratifying ppOS from 0.8 months (SIPS2), to 1.8 months (SIPS1), to 8.1 months (SIPS0) (p < 0.001). Thirty (14 %) patients received second-line systemic anticancer therapy with median ppOS 8.7 months. These patients had lower levels of systemic inflammation, as defined by albumin (p < 0.001), neutrophil count (p = 0.002), and SIPS (p = 0.004)), than all other patients.

CONCLUSIONS

SIPS, a simple biomarker of systemic inflammation, predicts ppOS after first-line pembrolizumab and may be useful alongside routine assessments of patient fitness to inform individualised discussions about subsequent treatment. We highlight poor outcomes in this patient group and a role for SIPS in signposting transition to best supportive care and early referral to palliative care. It may also help identify a small group of patients most likely to benefit from further lines of therapy.

Palliative Care Psychiatry: Building Synergy Across the Spectrum

PURPOSE OF REVIEW

Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry.

RECENT FINDINGS

PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.

Evidence-Based Nonpharmacological Symptom Management of Palliative Care in Advanced and Metastatic Cancer Patients: A Systematic Review

The aim of this systematic review is to provide reliable, high-quality data with an evidence-based, up-to-date overview of the use of nonpharmacologic interventions in the management of symptoms in advanced cancer patients with metastatic disease. A comprehensive literature search was performed by searching PubMed, EBSCO, Cochrane, and Google Scholar databases. "Nonpharmacologic," "palliative care," and "cancer" were the three main terms combined with the main symptoms of cancer palliative care such as "pain," "fatigue," "nausea and vomiting," "psychosocial distress," "loss of appetite," "dyspnea," "constipation," and "drowsiness," and each symptom was searched separately. Thirteen studies were included in this systematic review with a total of 1975 participants. Three of the studies examined "fatigue," three examined "quality of life," one examined "sleep," three examined "dyspnea," two examined "depression," and one examined "pain." To manage these symptoms, three of the studies included in the systematic review used "patient education," three of the studies used "exercise," three of the studies used "fan therapy," and the remaining studies used "reflexology," "cognitive behavioral therapy," and "occupational therapy." Number of studies done regarding the advanced and metastatic cancer patients and their symptom management through nonpharmacological methods are low, which makes it difficult to draw decisive conclusions.

Biomarkers of systemic inflammation provide additional prognostic stratification in cancers of unknown primary

BACKGROUND

Biomarkers of systemic inflammation have been shown to predict outcomes in patients with cancer of unknown primary (CUP). We sought to validate these findings in patients with confirmed CUP (cCUP) and explore their role alongside existing clinicopathological prognostic categories.

PATIENTS AND METHODS

CUP oncologist from across the United Kingdom were invited to include patients with cCUP referred to their local CUP multidisciplinary team. Patient demographics, clinical, pathological and outcome data were recorded and analysed.

RESULTS

Data were available for 548 patients from four CUP services. 23% (n = 124) of patients met clinicopathological criteria for favourable-risk cCUP. On multivariate analysis c-reactive protein (CRP) (p < 0.001) and the Scottish Inflammatory Prognostic Score (SIPS: combining albumin and neutrophil count) (p < 0.001) were independently predictive of survival. CRP and SIPS effectively stratified survival in patients with both favourable-risk and poor-risk cCUP based on clinicopathological features.

CONCLUSIONS

Biomarkers of systemic inflammation are reliable prognostic factors in patients with cCUP, regardless of clinicopathological subgroup. We recommend that CRP or SIPS are incorporated into routine clinical assessments of patients with cCUP as a tool to aid investigation and/or treatment decision-making across all groups. Established clinicopathological factors can then be used to inform management pathways and specific systemic anticancer therapy selection.

Barriers, blocks, and barricades: Disparities to access of palliative care in cancer care

Palliative care (PC) is specialized medical care for people living with a serious illness. PC models have stressed pain and symptom management, communication that is patient- and family-centric and longitudinal support for families living with serious illness that is contiguous across multiple settings. Despite the benefits that PC provides from a patient, family and quality of care standpoint, several barriers and disparities exist. Included in these barriers are the lack of geographic access to PC programs as well as the focus on inpatient, hospital-based PC programs versus outpatient and home-based models. Workforce shortages, challenges with defining and designing PC, and racial, cultural and language barriers have all contributed to disparities within PC. This review article outlines PC disparities including geographic access challenges, cross-cultural barriers and symptom and communication specific disparities. We discuss the impact these inequities have on patients living with cancer.

Using Functional Status at the Time of Palliative Care Consult to Identify Opportunities for Earlier Referral

Background: In order to improve early access to palliative care, strategies for monitoring referral practices in real-time are needed. Objective: To evaluate how Australia-Modified Karnofsky Performance Status (AKPS) at the time of initial palliative care consult differs between serious illnesses and could be used to identify opportunities for earlier referral. Methods: We retrospectively evaluated data from an inpatient palliative care consult registry. Serious illnesses were classified using ICD-10 codes. AKPS was assessed by palliative care clinicians during consult. Results: The AKPS distribution varied substantially between the different serious illnesses (p < 0.001). While patients with cancer and heart disease often had preserved functional status, the majority of patients with dementia, neurological, lung, liver, and renal disease were already completely bedbound at the time of initial palliative care consult. Conclusion: Measuring functional status at the time of palliative care referral could be helpful for monitoring referral practices and identifying opportunities for earlier referral.

Palliative Care Physicians' Perceptions of Conditions Required to Provide Early Palliative Care

CONTEXT

Early palliative care (EPC) is widely recommended but its implementation may be challenging.

OBJECTIVES

We conducted a qualitative analysis of Canadian palliative care physicians' opinions about conditions necessary to provide EPC.

METHODS

A survey assessing attitudes and opinions regarding EPC was distributed to physicians providing primary or specialized palliative care, as identified by the Canadian Society of Palliative Care Physicians. The survey included an optional final section for respondents' general comments; we screened these for relevance to our study aims and conducted a thematic analysis of relevant comments.

RESULTS

Of 531 completed surveys, 129 (24%) respondents provided written comments, of whom 104 mentioned conditions they felt to be necessary to provide EPC. Four key themes were identified: 1) Clear delineation of roles of primary and specialized palliative care physicians-all physicians should be empowered to provide primary palliative care, with specialists providing additional support; 2) Shared care with needs-dependent referral-primary and specialized palliative care physicians should work collaboratively, with referral to specialized palliative care based on need rather than on prognosis; 3) Adequate resources to support primary palliative care-education, financial incentives, and collaboration with interdisciplinary team members such as nurses and specialized providers were specifically mentioned; 4) Addressing the misconception that palliative care equals end-of-life care-there was particular emphasis on education of both healthcare providers and the public.

CONCLUSION

Changes are necessary at the level of palliative care referral systems, providers, resources, and policy to enable implementation of EPC.

Telehealth palliative care interventions for patients with advanced cancer: a scoping review

PURPOSE

Telehealth allows patients to maintain contact with healthcare providers without necessitating travel, and is becoming increasingly utilized. The purpose of this study is to describe the components of telehealth palliative care interventions for patients with advanced cancer before the COVID-19 pandemic; identify any intervention components associated with improvements in outcomes; and evaluate reporting of interventions.

METHODS

This scoping review was registered on the Open Science Framework. We searched 5 medical databases from inception to June 19, 2020. Inclusion criteria were: age ≥ 18, advanced cancer, asynchronous or synchronous telehealth intervention, and specialized palliative care interventions in any setting. We assessed the quality of intervention reporting using the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

Twenty-three studies met the inclusion criteria: 15 (65%) quantitative (7 randomized controlled trials, 5 feasibility trials, 3 retrospective chart reviews); 4 (17%) mixed methods, and 4 (17%) qualitative. Most quantitative and mixed methods studies were conducted in North America (12/19, 63%), reported on hybrid (in-person and telehealth) interventions (9/19, 47%), and were delivered by nurses (12/19, 63%) in the home setting (14/19, 74%). In most studies that reported improvements in patient- or caregiver-reported outcomes, the content was psychoeducational and resulted in improvements for psychological symptoms. No study provided complete reporting on all 12 TIDieR checklist items.

CONCLUSION

Telehealth studies are needed that reflect palliative care's mission to provide multidisciplinary team-based care that improves quality of life in diverse settings, and that provide detailed reporting of interventions.

Integrating Palliative Care into Oncology Care Worldwide: The Right Care in the Right Place at the Right Time

OPINION STATEMENT

While the benefits of early palliative care are indisputable, most of the current evidence has emerged from resource-rich settings in urban areas of high-income countries, with an emphasis on solid tumors in outpatient settings; this model of palliative care integration is not currently scalable internationally. A shortage of specialist palliative care clinicians means that in order to meet the needs of all patients who require support at any point along their advanced cancer trajectory, palliative care must also be provided by family physicians and oncology clinicians who require training and mentorship. Models of care that facilitate the timely provision of seamless palliative care across all settings (inpatient, outpatient, and home-based care), with clear communication between clinicians, are crucial to the provision of patient-centred palliative care. The unique needs of patients with hematological malignancies must be further explored and existing models of palliative care provision modified to meet these needs. Finally, care must be provided in an equitable and culturally sensitive manner, recognizing the challenges associated with the delivery of high-quality palliative care to both patients in high-income countries who live in rural areas, as well as to those in low- and middle-income countries. A one-size-fits-all model will not suffice, and there is an urgent need to develop innovative context-specific models of palliative care integration worldwide, in order to provide the right care, in the right place, and at the right time.

National Survey Using CFIR to Assess Early Outpatient Specialty Palliative Care Implementation

CONTEXT

The American Society of Clinical Oncology (ASCO) recommends that outpatient specialty palliative care (OSPC) be offered within eight weeks of an advanced cancer diagnosis. To meet the rising demand, there has been an increase in the availability of OSPC services at National Cancer Institute (NCI)-designated cancer centers; however, many OSPC referrals still occur late in the disease course.

OBJECTIVES

Using the Consolidated Framework for Implementation Research (CFIR), we evaluated facilitators and barriers to early OSPC implementation and associated clinic characteristics.

METHODS

We selected relevant CFIR constructs for inclusion in a survey that was distributed to the OSPC clinic leader at each NCI-designated cancer center. For each statement, respondents were instructed to rate the degree to which they agreed on a five-point Likert scale. We used descriptive statistics to summarize responses to survey items and explore differences in barriers based on OSPC clinic size and maturity.

RESULTS

Of 60 eligible sites, 40 (67%) completed the survey. The most commonly agreed upon barriers to early OSPC included inadequate number of OSPC providers (73%), lack of performance metric goals (65%), insufficient space to deliver early OSPC (58%), logistical challenges created by early OSPC (55%), and absence of formal interdisciplinary communication systems (53%). The most frequently reported barriers differed according to clinic size and maturity.

CONCLUSION

Most barriers were modifiable in nature and related to the "Inner Setting" domain of the CFIR, which highlights the need for careful strategic planning by leadership when implementing early OSPC.

Patient & Caregiver Experiences: Qualitative Study Comparison Before and After Implementation of Early Palliative Care for Advanced Colorectal Cancer

BACKGROUND

The Palliative Care Early and Systematic (PaCES) program implemented an early palliative care pathway for advanced colorectal cancer patients in January 2019, to increase specialist palliative care consultation and palliative homecare referrals more than three months before death. This study aimed to understand the experience of patients with advanced colorectal cancer and family caregivers who received early palliative care supports from a specialist palliative care nurse and compared those experiences with participants who experienced standard oncology care prior to implementation of early palliative care.

METHODS

This was a qualitative and patient-oriented study. We conducted semi-structured telephone interviews with two cohorts of patients with advanced colorectal cancer before and after implementation of an early palliative care pathway. We conducted a thematic analysis of the transcripts guided by a Person-Centred Care Framework.

RESULTS

Seven patients living with advanced colorectal cancer and five family caregivers who received early palliative care supports expressed that visits from their early palliative care nurse was helpful, improved their understanding of palliative care, and improved their care. Four main themes shaped their experience of early palliative care: care coordination, perception of palliative care & advance care planning, coping with advanced cancer, and patient and family engagement. These findings were compared with experiences of 15 patients and seven caregivers prior to pathway implementation.

CONCLUSION

An early palliative care pathway can improve advanced cancer care, and improve understanding and acceptance of early palliative care. This work was conducted in the context of colorectal cancer but may have relevance for the care of other advanced cancers.

The adult and pediatric palliative care: differences and shared issues

Adult and pediatric palliative care (PC) share common aims and ethical principles but differ in many organizational and practical aspects. The aim of this narrative review is to analyze these differences and focus on which key aspects of pediatric palliative care could integrate adult services for a better care of suffering patients.Interventions which are peculiar of pediatric PC respect to adult PC include: an earlier referral to the PC service to identify the needs and plan the interventions at an earlier stage of the disease; consequently, a more systematic cooperation with the disease-specific physicians to reduce the burden of treatments; a better integration with the community and the social surroundings of the patients, to prevent social isolation and preserve their social role; a more dynamic organization of the PC services, to give patients the chance of being stabilized at in-hospital or residential settings and subsequently discharged and cared at home whenever possible and desired; the implementation of respite care for adults, to help the families coping with the burden of the disease of their beloved and promote the home-based PC.This review underlines the relevance of some key-aspects of pediatric PC that can be beneficial also within PC of adults. Its findings give the chance for a more dynamic and modern organization of adult PC services and may serve as a basis of future research for new interventions.

Palliative care referrals in patients with pulmonary arterial hypertension: The Pulmonary Hypertension Association Registry

BACKGROUND

Pulmonary arterial hypertension (PAH) is a life limiting disease with substantial symptom burden and healthcare utilization. Palliative care alleviates physical and emotional symptoms for patients with serious illness, and has been underutilized for these patients.

OBJECTIVE

To characterize patients with PAH referred to palliative care and identify predictors of referral.

METHODS

We conducted an observational study of adult patients enrolled in the Pulmonary Hypertension Association Registry from January 2015 through June 2021, performing descriptive statistics on patient characteristics at baseline for all patients and the subset referred to palliative care. These characteristics were modeled in a backwards elimination Cox regression with time to referral to palliative care as the primary outcome.

RESULTS

92 of 1,578 patients were referred to palliative care (5.8%); 43% were referred at their last visit prior to death. Referrals were associated with increasing age per decade (hazard ratio 1.35 [95% confidence interval 1.16-1.58]), lower body mass index (hazard ratio 0.97 [95% confidence interval 0.94-0.998]), supplemental oxygen use (hazard ratio 2.01 [95% confidence interval 1.28-3.16]), parenteral prostanoid use (hazard ratio 2.88 [95% confidence interval 1.84-4.51]), and worse quality of life, measured via lower physical (hazard ratio 0.97 [95% confidence interval 0.95-0.99]) and mental (hazard ratio 0.98 [95% confidence interval 0.96-0.995]) scores on the 12-item Short Form Health Survey.

CONCLUSION

Patients with PAH are infrequently referred to palliative care, even at centers of excellence. Referrals occur in sicker patients with lower quality of life scores, often close to the end of life.

Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral

PURPOSE

Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center.

METHODS

Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category.

RESULTS

LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER.

CONCLUSION

A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.

Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care

BACKGROUND

Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral.

AIM

To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice.

METHODS

A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported.

RESULTS

Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice.

CONCLUSION

The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.

Early integration of palliative care for patients with haematological malignancies

Early palliative care (EPC) significantly improves quality of life, symptoms, and satisfaction with care for patients with advanced cancer. International organizations have recognized and promoted the role of palliative care as a distinct specialty, advocating its involvement throughout the cancer trajectory. Although patients with haematologic malignancies (HMs) have a comparable symptom burden to patients with solid tumours, they face multiple barriers to EPC integration. In this review, we discuss these barriers, present updated evidence from clinical trials of EPC in HMs and propose models to support EPC integration into care for patients with HMs.

Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study

Background

The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges.

Methods

An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care.

Results

We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms “managed/resolved” (75.2%), and/or the “patient wishes to die/for care at home” (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in “who” will be following up “what” in the discharge letters, and whether described patients’ needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes “complexity” and “complex pain”.

Conclusions

The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01038-8.

Integration of Palliative and Supportive Care Into the Management of Genitourinary Malignancies

Patients with genitourinary malignancies are typically cared for by a multidisciplinary team of urologists, medical oncologists, and radiation oncologists. For the past decade, integration of palliative and supportive care (PSC) into routine oncological care has been advocated by leading oncology organizations. Despite these recommendations, current evidence suggests that integration of PSC for patients with routine genitourinary malignancies is lacking. In this article, we first review the current evidence for integration of palliative care and the data suggesting an unmet need for people with genitourinary malignancies. We then provide a potential framework that examines the needs of these patients. We show an example of a potential opportunity for integration of PSC into routine multidisciplinary oncologic care that can help improve patient care by meeting these unmet patient needs. Finally, we discuss potential opportunities for integration of PSC that can provide an opportunity to understand the mechanism of benefit of PSC for improving patient-centered care.

Simultaneous Care in Oncology: A 7-Year Experience at ESMO Designated Centre at Veneto Institute of Oncology, Italy

Benefits of early palliative care referral in oncology are well-validated. At the Veneto Institute of Oncology-IRCCS, a simultaneous-care outpatient clinic (SCOC) has been active since 2014, where patients with advanced cancer are evaluated by an oncologist together with a palliative care team. We prospectively assessed SCOC patients’ characteristics and SCOC outcomes through internal procedure indicators. Data were retrieved from the SCOC prospectively maintained database. There were 753 eligible patients. The median age was 68 years; primary tumor sites were gastrointestinal (75.2%), genitourinary (15.0%) and other sites (9.8%). Predominant symptoms were psychological issues (69.4%), appetite loss (67.5%) and pain (65.9%). Dyspnea was reported in 53 patients (7%) in the referral form, while it was detected in 226 patients (34.2%) during SCOC visits (p < 0.0001). Median survival of patients after the SCOC visit was 7.3 months. Survival estimates by the referring oncologist were significantly different from the actual survival. Psychological intervention was deemed necessary and undertaken in 34.6% of patients, and nutritional support was undertaken in 37.9% of patients. Activation of palliative care services was prompted for 77.7% of patients. Out of 357 patients whose place of death is known, 69.2% died at home, in hospice or residential care. With regard to indicators’ assessment, the threshold was reached for 9 out of 11 parameters (81.8%) requested by the procedure. This study confirmed the importance of close collaboration between oncologists and palliative care teams in responding properly to cancer patients’ needs. The introduction of a procedure with indicators allowed punctual assessment of a team’s performance.

Effect of a Palliative Care Screening Tool for Oncology Patients

This pilot quality improvement project implemented an adapted screening tool within an outpatient oncology center for patients with advanced cancer to identify unmet patient needs, aid decision making, and increase the number of patients referred to palliative care. Baseline data were collected via retrospective convenience sampling to track the number of palliative care referrals generated from the oncology center. Over a 6-week period, screening was implemented during patient evaluations with their oncologist to identify needs for palliative care intervention and as a decision aid to support referring patients to a specialized palliative care service. During the pilot, key nursing staff were affected by COVID-19, and the ideal sample size was not met. Despite a small sample size, the number of palliative care referrals increased. The increased number of referrals affirms the use of a screening tool to identify palliative care needs and as a formal decision-making process to improve patient access to palliative care.

Initiating early palliative care for older people with advanced cancer and its barriers

PURPOSE OF REVIEW

Early palliative care (EPC) is known to generally improve both health-related quality of life (QoL) and symptom intensity at small effect sizes. However, it is unclear whether EPC is effective in older people, a population that is notoriously unaccounted for. This review summarizes the recent evidence concerning the efficacy of EPC in older patients with advanced cancer and delineates existing barriers to accessing respective services.

RECENT FINDINGS

The search for studies published in MEDLINE from January 2020 to September 2021 yielded six relevant records. Data from a recent feasibility trial and subgroups from larger randomised trials point to a somewhat lesser decline in QoL for patients undergoing EPC compared to those receiving treatment as usual. However, enrolling older patients in such trials remains a major challenge mostly due to them feeling too ill to participate.

SUMMARY

For older patients, the efficacy of EPC, like many other medical interventions, has hardly been studied so far. Existing work yielded several specific barriers for older patients to access this type of care. Future research should prioritize efficacy trials of EPC tailored to the needs of older patients enabling clinicians to enter truly evidence-based shared decision-making with their patients.

The influence of symptom severity of palliative care patients on their family caregivers

Background

This study anlyzed whether family caregivers of patients with advanced cancer suffer impaired sleep quality, increased strain, reduced quality of life or increased care burden due to the presence and heightened intensity of symptoms in the person being cared for.

Method

A total of 41 patient-caregiver dyads (41 caregivers and 41 patients with advanced cancer) were recruited at six primary care centres in this cross-sectional study. Data were obtained over a seven-month period. Caregiver’s quality of sleep (Pittsburgh Sleep Quality Index), caregiver’s quality of life (Quality of Life Family Version), caregiver strain (Caregiver Strain Index), patients’ symptoms and their intensity (Edmonton Symptom Assessment System), and sociodemographic, clinical and care-related data variables were assessed. The associations were determined using non-parametric Spearman correlation.

Results

Total Edmonton Symptom Assessment System was significantly related to overall score of the Pittsburgh Sleep Quality Index (r = 0.365, p = 0.028), the Caregiver Strain Index (r = 0.45, p = 0.005) and total Quality of Life Family Version (r = 0.432, p = 0.009), but not to the duration of daily care (r = -0.152, p = 0.377).

Conclusions

Family caregivers for patients with advanced cancer suffer negative consequences from the presence and intensity of these patients’ symptoms. Therefore, optimising the control of symptoms would benefit not only the patients but also their caregivers. Thus, interventions should be designed to improve the outcomes of patient-caregiver dyads in such cases.

Incorporating palliative care principles to improve patient care and quality of life in urologic oncology

Palliative care - specialized healthcare focused on improving quality of life for patients with serious illnesses - can help urologists to care for patients with unmet symptom, coping and communication needs. Society guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend incorporating palliative care into standard oncological care, based on multiple randomized trials demonstrating that it significantly improves physical well-being, patient satisfaction and goal concordant care. Misconceptions regarding the objective and ideal timing of palliative care are common; a key concept is that palliative care and treatments seeking to cure or prolong life are not mutually exclusive. Urologists are well positioned to champion the integration of palliative care into surgical urologic oncology and should be aware of palliative care guidelines, indications for palliative care use and how the field of urologic oncology can adopt best practices.

What are determinants of utilisation of pharmaceutical anticancer treatment during the last year of life in Norway? A retrospective registry study

OBJECTIVES

The objective of this study was to investigate the use of, and predictors for, pharmaceutical anticancer treatment (PACT) towards the end of a patient's life in a country with a public healthcare system.

DESIGN

Retrospective registry study.

SETTING

Secondary care in Norway.

PARTICIPANTS

All Norwegian patients with cancer (International Classification of Diseases tenth revision (ICD-10) codes C00-99, D00-09, D37-48) in contact with a somatic hospital in Norway between 2009 and 2017 (N=420 655). Analyses were performed on a subsample of decedents with follow-back time of more than 1 year (2013-2017, N=52 496).

INTERVENTIONS

N/A.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients receiving PACT during the last year and month of life. We calculated CIs with block bootstrapping, while predictors of PACT were estimated with logistic regression.

RESULTS

24.0% (95% CI 23.4% to 24.6%) of the patients received PACT during the last year of life and 3.2% (95% CI 3.0% to 3.5%) during their final month. The proportion during the last month was highest for multiple myeloma (12.7%) and breast cancer (6.5%) and lowest for urinary tract (1.1%) and prostate and kidney cancer (1.4%). Patients living in northern (OR 0.80, 95% CI 0.68 to 0.94) and western (OR 0.85, 95% CI 0.75 to 0.96) Norway had lower odds of PACT during the last month, while patients with myeloma (OR 3.0, 95% CI 2.5 to 3.7) and breast (OR 1.4, 95% CI 1.1 to 1.6) had higher odds. Kidney cancer (OR 0.25, 95% CI 0.2. to 0.4), urinary tract (OR 0.38, 95% CI 0.3 to 0.5) and prostate cancer (OR 0.4, 95% CI 0.3 to 0.5) were associated with lower probability of receiving PACT within the last month.

CONCLUSIONS

The proportion of patients receiving PACT in Norway is lower than in several other industrialised countries. Age, type of cancer and area of living are significant determinants of variation in PACT.

Using Process Indicators to Monitor Documentation of Patient-Centred Variables in an Integrated Oncology and Palliative Care Pathway-Results from a Cluster Randomized Trial

BACKGROUND

Despite robust evidence from randomized controlled trials (RCTs) demonstrating clinical and patient-reported benefits of integrated oncology and palliative care, the tumour-centred focus is predominant. This single-centre process evaluation monitors documentation of required patient-centred variables during an RCT.

METHODS

Performance status, patient self-reported symptoms, weight and summaries to general practitioners were assessed from June 2017 to July 2020 in three consultation types: first oncological after study inclusion and palliative and oncological consultations during chemotherapy. Descriptive statistics were used to monitor if the pre-defined program fulfilment of ≥85% documentation was reached.

RESULTS

435 consultations were monitored in 76 patients; 60.5% males, 86.8% with GI cancers; 76 (17.5%) were from the first oncological consultations, 87 (20.0%) and 272 (62.5%) from palliative or subsequent oncological consultations. Program fulfilment differed across consultation types with 94.8% in the palliative consultations (83.3-100%), relative to 65.8% (62.5-75.0%) and 69.2% (57.0-84.3%) for first and subsequent oncological consultations over time, respectively. Use of self-reported symptoms was consistently lower in the oncological consultations.

CONCLUSIONS

The documentation level of required core variables was not satisfactory, notwithstanding their high clinical relevance and continuous reminders during study. Pre-trial optimization strategies are paramount to promote integration and reduce professional and personal barriers towards a more patient-centred focus.

Models of Integration of Specialized Palliative Care with Oncology

OPINION STATEMENT

Evidence from randomized controlled trials and meta-analyses has shown that early integration of specialized palliative care improves symptoms and quality of life for patients with advanced cancer. There are various models of early integration, which may be classified based on setting of care and method of palliative care referral. Most successful randomized controlled trials of early palliative care have used a model of specialized teams providing in-person palliative care in free-standing or embedded outpatient clinics. During the COVID-19 pandemic, telehealth has become a prominent model for palliative care delivery. This model of care has been well received by patients and palliative care providers, although evidence to date is limited. Despite evidence from trials that routine early integration of palliative care into oncology care improves patient outcomes, referral to palliative care still occurs mostly according to the judgment of individual oncologists. This hinders equitable access to palliative care and to its known benefits for patients and their caregivers. Automated referral based on triggering criteria is being actively explored as an alternative. In particular, routine technology-assisted symptom screening, combined with targeted needs-based automatic referral to outpatient palliative care, may improve integration and ultimately increase quality of life.