Canadian Study Looks at an Integrated Palliative Care Model

A Conversation With Camilla Zimmermann, MD, PhD




The patients in our study endorsed the integrated model of early palliative care and oncology. It simply produces better outcomes.
— Camilla Zimmermann, MD, PhD

Although initiation of palliative care from the time of cancer diagnosis produces optimal outcomes for patients, this strategy is often not practiced. A recent Canadian study conducted in patients with advanced cancer and their caregivers examined the opinions of patients with advanced cancer and their caregivers who participated in a trial of early palliative care regarding the respective roles of their oncologist and their palliative care physician.1 The ASCO Post recently spoke to the trial’s lead author, Camilla Zimmermann, MD, PhD, Senior Scientist and Head of the Division of Palliative Care, Princess Margaret Cancer Centre, Toronto.

Professional Focus

Please tell our readers a bit about your background and current work.

I’m a palliative care physician, and my clinical work is in oncology care. My research is focused mainly on early palliative care intervention. This is basically the policy of offering palliative care way in advance of current practice, which tends to bring in palliative care services in the last 2 months of a cancer patient’s life. Studies have demonstrated that early initiation of palliative care services produces better outcomes among patients with cancer.2-4

Despite progress, however, there remain barriers to early adoption of clinical interventions that would work in partnership with the oncologist and may produce better quality-of-life outcomes for our patients.

Study Details

Please describe your study, its aim, and results.

The recent analysis was a substudy of a larger randomized controlled trial of 461 patients, in which the patients were cluster-randomized to early palliative care intervention or routine oncology care.4 Among 24 clinics, 12 received the early palliative care intervention and 12 were randomized to routine oncology care. After the 4-month trial, we conducted one-on-one qualitative semistructured interviews, which we analyzed using grounded theory, a systematic method that constructs a theory through the analysis of data.

We asked patients and their caregivers in both cohorts what they thought the role of their oncologist was. The early palliative care group was also asked how they defined the role of their palliative care team. We had all of the interviews transcribed and analyzed the responses in order to develop themes. The results fell into three main categories, which related to the focus of care, the model of care delivery, and the manner in which the care from oncology and palliative care complemented each other to improve the patient and caregiver experience. 

The patients and their primary caregivers felt that their oncologist focused predominantly on the tumor and that the aim of the oncologist was to keep the patient alive as long as possible and direct the treatment to that end. In contrast, the patients and their caregivers viewed the palliative care team’s focus as centering on symptom control, particularly of pain. They also saw the palliative care team’s approach as more holistic, looking at the entire person, not just the disease.

Moreover, they saw their palliative care doctors not only as symptom specialists, but also as “interpreters of care”—that is, interpreting, for the patient and caregiver, what the cancer was doing and answering complicated questions they had about care that the oncologist didn’t answer. The palliative care specialists served as a sounding board and as doctor-therapists, providing emotional support for the patient and caregiver.

When asked about the model of care, the patients and caregivers saw oncology care as highly structured, based on the specific protocol of therapy. The oncology model was also perceived as very time-limited, leaving patients feeling that if they wanted to get their own issues addressed, they had to be very assertive, to the point that some felt they were almost intrusive. On the other hand, they felt that the palliative care visits were much less formal and with far less pressure on time. In short, patients sensed that they were in control of these visits, as opposed to the more structured oncologist-led visits.

On the third question about how the two care models worked, patients and caregivers felt that concurrent palliative care alongside oncologic care made their overall health-care experience more rewarding and holistic. They felt that each team had its own focus and that one wasn’t necessarily better than the other, but working together produced the best patient outcomes.

What was the overall conclusion?

I think it is clear that we need to foster a system that combines palliative and oncology care in a coordinated way. It is also beneficial to educate oncologists so that they can provide a certain amount of palliative care to their patients. There shouldn’t be a segregated model that separates the disciplines.

Of course, this kind of coordination varies between settings. Oncology practices that are time-constrained would find it very difficult to engage in complex palliative and end-of-life discussions, so that’s where the palliative care team would be needed.

Barriers to Palliative Care

Did your study identify barriers to early initiation of palliative care?

In Canada, we don’t have the same reimbursement barriers that exist in the United States; for example, there’s no hospice benefit in which the patient has to choose between active care and palliation. However, I think the main barrier to initiating palliative care in Canada is the misperception that it is solely end-of-life care. Several of the patients and caregivers interviewed for our study expressed fear that seeing a palliative care specialist meant that death was ­imminent.

This mindset is found not solely among patients, as it also still exists among a percentage of health-care providers. Furthermore, a lack of palliative care specialists limits access to services, but we’re making progress in that ­department.

Closing Thoughts

Do you have any last thoughts on your research?

Palliative care is relevant from the point of cancer diagnosis throughout the continuum of care, helping the patient navigate through the illness up until the point of death. We need further studies to assess the role of family physicians in providing palliative care and more educational interventions for oncologists in palliative care. The patients in our study endorsed the integrated model of early palliative care and oncology. It simply produces better outcomes. That’s the main message from our research. ■

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

References

1. Hannon B, Swami N, Pope A, et al: Early palliative care and its role in oncology: A qualitative study. Oncologist. July 22, 2016 (early release online).

2. Temel JS, Greer JA, El-Jawahri A, et al: Effects of early integrated palliative care in patients with lung and GI cancer: A randomized clinical trial. J Clin Oncol. December 28, 2016 (early release online).

3. Hui D, Bruera E: Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol 13:159-171, 2016.

4. Zimmermann C, Swami N, Krzyzanowska M, et al: Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 383: 1721-1730, 2014.



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