Integrating Early Palliative Medicine Into Oncology Care to Improve Patients’ Quality of Life

A Conversation With Vicki Jackson, MD, MPH




We will only be able to do a complete job of caring for patients if we approach their care as a team. And the key to accomplishing that is to hold one another in high regard. After all, we all want the same thing: to help patients do as well as they can for as long as they can.
— Vicki Jackson, MD, MPH

At the 2015 Palliative Care in Oncology Symposium in Boston, Vicki Jackson, MD, MPH, Chief in the Division of Palliative Care and Geriatrics at Massachusetts General Hospital, Co-Director of the Harvard Center for Palliative Care, and Associate Professor of Medicine at Harvard Medical School, delivered the keynote lecture on the effective integration of palliative medicine into cancer care. The lecture grew out of Dr. Jackson’s research with her colleague Jennifer S. Temel, MD, on the successful integration of early palliative care into standard oncology care for patients with advanced non–small cell lung cancer.

The study found that the combination of palliative care and oncology care resulted not just in meaningful improvements in patients’ quality of life and mood, but also prolonged their survival by about 2 months.1 Dr. ­Jackson’s research has led her to design interventions for oncologists that incorporate palliative care approaches into their practices. She has also developed a communication curriculum for physicians on how to deliver prognostic information to patients.

Jennifer S. Temel, MD

Jennifer S. Temel, MD

The ASCO Post talked with Dr. ­Jackson about the importance of integrating palliative care into oncology practice, how to avoid sending mixed messages to patients, and the increasing acceptance by both oncologists and patients of early palliative medicine in oncology care.

Distinct Roles and Relationships

Why is it important for oncologists and palliative care specialists to work together to improve care for patients with cancer?

Oncologists develop very connected, close relationships with their patients. As a result, patients are sometimes reluctant to talk with their oncologist about symptoms that are bothering them because they worry that their oncologist will think he or she has let them down, or that the patient is not strong enough to have additional treatment. Often, patients feel freer to discuss these issues with another medical professional with whom they have a newer relationship or a relationship that isn’t largely focused around treatment decisions.

It is important for all oncologists to have primary palliative care skills as well as to know how to have goals-of-care conversations with their patients, how to manage symptoms and elicit information about quality of life, and when the addition of a palliative care specialist to the team would be beneficial.

Palliative care physicians also have very connected relationships with their patients, but I think the contract is different. We frequently see patients more often and are not engaged in treatment decision-making in the same way as a medical oncologist. Patients will often ask for our opinion about chemotherapy and other cancer treatments, but we are not the arbiters of whether the treatment is delivered.

Co-management Models of Care

How does the co-management model of oncology care and palliative care work in real-world practice? Is this type of integration only available in large academic cancer centers?

No. I know of several co-management models in community settings in addition to those available in academic settings. The key piece for the success of this type of care is the ability to have the two disciplines in the same ­location.

In our clinic, for example, we are fortunate to have our palliative care outpatient office on the same floor with the medical oncology department, so we are able to have frequent contact with specialists in lung cancer, gastrointestinal cancer, genitourinary cancer, and other cancers and are able to have joint visits with patients.

Unmet Palliative Care Needs

Is this model of care appropriate for every stage of the disease course, or is it most commonly used at the end of life?

All of our outpatient work has been with patients who have incurable cancers but are seen from the time of their diagnosis until the end of life. This type of collaboration works very effectively in the early course of a patient’s cancer, and we have even developed an inpatient collaborative model for patients undergoing bone marrow transplant.

So, it doesn’t matter what the type of treatment is. What is most important to consider is whether the patient has an unmet palliative care need that another clinician can effectively address.

In fact, we have demonstrated in our studies that patients who receive early palliative care have an improved quality of life and a lower rate of depression. The first study we did indicated that there was longer survival in the intervention group that received palliative care.1

Avoiding Mixed Messages

How can the oncologist and palliative care physician speak with one voice in discussions with patients?

One important way to have a unified message for patients is for both the oncologist and palliative care physician to be clear about the goal of treatment and to effectively communicate that message to patients. Is the goal cure, to prolong life, or to mitigate symptoms?

For example, if the goal of prescribing chemotherapy is to shrink the patient’s tumor to relieve symptoms and help the patient feel better, but in fact the treatment makes the patient feel worse, that is a conversation we should all have together to determine how to meet the intended goal. If the goal of treatment is to cure the patient of cancer, then my job is to help the patient feel as well as possible to be able to undergo that treatment.

Education in Palliative Care

How can institutions provide the education oncologists may need to talk to their patients effectively about the role of palliative medicine?

What has been most helpful in our institution is the practice of having joint visits with patients. I’ve learned a lot about oncology care that way, and oncologists have learned about the benefits of palliative medicine and the many ways it can be helpful to patients undergoing active treatment.

Having palliative care clinicians describe what they do to oncologists and provide suggestive language for how they can recommend palliative care to patients is also beneficial.

Palliative care is often equated with end-of-life care, and although hospice care is part of what I do, it is only a small part. The vast majority of my time is spent helping patients live as well as they can with their cancer while they undergo active treatment.

Explaining to Patients

Please give some examples of effective language oncologists can use to introduce palliative care to their patients?

We suggest oncologists explain that they are partnering with a palliative care physician who specializes in symptom management and quality-of-life concerns to ensure that the patient feels as well as he or she can while undergoing treatment. Oncologists need to be prepared to describe how palliative care is different from hospice care and that palliative care is available for any patient with a serious illness, regardless of prognosis.

Integration of Palliative Care

Is palliative care becoming more of an integral part of the total care patients ­receive?

Yes, absolutely. What we are seeing is that oncologists are starting to view palliative care physicians as just another member of the interdisciplinary team trying to help patients do as well as possible with their cancer and its treatment. We are also finding that patients are more understanding of the role of palliative medicine and how it can be beneficial in their overall care.

A key piece of how comfortable patients are is how comfortable their oncologists are with this type of co-management care, which is why joint visits with patients are so important. When we are all in the same room together, it helps patients understand our individual roles and the goals of treatment better.

As I mentioned earlier, it is not uncommon for patients to feel that they have heard different messages from different clinicians. A crucial part of successful collaboration is for the palliative care physician and the oncologist to hold each other in high regard and to recognize the reality that patients feel comfortable discussing different aspects of their care with different people—and to be glad patients are able to do that.

We will only be able to do a complete job of caring for patients if we approach their care as a team. And the key to accomplishing that is to hold one another in high regard. After all, we all want the same thing: to help patients do as well as they can for as long as they can. ■

Disclosure: Dr. Jackson reported no potential conflicts of interest.

Reference

1. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med 363:733-742, 2010.



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