Palliative Care Expert Provides Insight Into Best Practices

Craig D. Blinderman, MD, MA

A consensus has emerged among oncology practitioners that palliative care should not be seen as end-of-life care but is best deployed early to help patients and their caregivers manage symptoms throughout the cancer treatment trajectory.

OncLive

discussed what this approach means for the future of palliative care with Craig D. Blinderman, MD, MA, the director of the Adult Palliative Medicine Service at Columbia University Medical Center/New-York Presbyterian Hospital and Co-Director of the Center for Supportive Care and Clinical Ethics in the Department of Medicine

There has been an emphasis on starting palliative care earlier on in treatment. What signals should practitioners be looking for to start palliative care?

In a study done in 2010 that I was a part of, we looked at randomizing early palliative care for patients with advanced lung cancer versus treating with standard oncologic therapy. There were some significant benefits associated with the randomization group who received palliative care early on. Benefits included improved quality of life, decreases in depression, and increased survival.

ASCO issued a statement recommending that clinicians who are treating patients with metastatic cancer, especially lung cancer, should consider palliative care at the moment of diagnosis. And so rather than thinking about waiting for the patient to really be suffering with symptoms or coping poorly as the disease progresses, physicians should think about integrating palliative care right off the bat. Just like we have nutrition services and other kinds of supportive services at the beginning of their cancer treatment, we should also be doing that with palliative care.

The main problem is concerns staffing—having enough well-trained specialists in palliative care and pain management to actually meet the needs of this large population. So there’s a balance between wanting to get all these patients in and see them and make sure they’re getting specialized palliative care, and at the same time, knowing that we can’t necessarily do that at all institutions. So, we need to bring up the generalist level of expertise of oncology and other practitioners to do some of this work, and then maybe refer back to us when they start to realize that their pain management or symptom management or some of their approaches are not sufficient or they need additional help or extra support.

There are a lot of terms used: palliative care, supportive care, hospice. What are the differences between all these terms?

A lot of patients, including physicians, are confused about the terms and sometimes equate palliative care with hospice care. Palliative came out of the oncology literature. Things are either considered curative or palliative when you think about a treatment approach. So palliative became equated with the idea of “I can’t be treated, so I must be going to hospice,” or something like that. And that’s not the case. We’re trying to rebrand the idea that palliative care is an integrative approach to care for patients with serious illnesses like cancer to provide an extra layer of support to them, to their families, to the oncologists, and the other treating physicians to manage pain, other symptoms, alleviate suffering, things like that.

Hospice is for patients at the very last stage of life. Typically within the last 6 months of life. They become eligible for hospice service, which is largely a home care program to keep patients comfortable at the end of life.

Palliative care can be integrated with disease modifying therapies such as chemotherapy, radiation therapy. So we’re trying to consider it more upstream as part of the whole comprehensive care of patients.

It’s true that the term supportive care and palliative care are equated, and in my mind it’s not so problematic. From my perspective, if it works to get patients incorporated into a care plan that includes a palliative care clinician and we call it supportive care, that’s what we’re really trying to do: wrap them with more support—the patients, the family and so forth, and that’s fine.

The program that we have here is under a center called “Supportive Care and Clinical Ethics,” where we work together with the head of ethics to try to provide a program both of education, clinical programming and starting to do some research to really foster this idea that we’re here to support patients, families, and the treating physicians themselves. And convey that we’re trained palliative care clinicians to do that, but it doesn’t matter so much to me if we call it palliative care or supportive care in that sense.

What kind of people should be part of a multidisciplinary team to carry out palliative care to cancer patients?

A trained palliative care physician can’t do this alone. It’s just not possible. Our teams in the hospitals as well as the team that I’m building on the outpatient side includes nursing, nurse practitioners, typically, RN’s as well, social workers, chaplains. Some teams will also include people from ethics, psychiatry, psychology, nutrition, and so forth.

The center that we’re building here is ultimately going to include nutrition, maybe even some integrative therapy practitioners who provide such services as acupuncture, Reiki, and massage, along with the nurses and social workers.

And why is that important? I think that’s the crucial question because it’s not just giving patients pain medications or treating their nausea. When we think about suffering, suffering is something that the person experiences. And the person is more than just the physical symptoms and physical aspects of his or her body. There are their psychological, emotional states, their social suffering that they might experience, plus existential or spiritual suffering, and all that needs to be understood and assessed and managed. So it’s not appropriate to just have it come from a medically trained person, but to actually have the other components so we can really address all the ways in which patients are suffering through their treatments and to the end of their lives, as it may be.

Assuming you have all the correct people in place for that team, what further challenges face palliative care and pain management in general?

I think palliative care is misunderstood—the misperception that maybe it means that end of life, that there’s no hope for them, or there’s nothing more that we can do. This, I think, is a real barrier, especially among oncologists and other providers who think the moment they introduce patients to a palliative care team, that means that they’re not helping them any further.

Oncology providers need to rethink these notions. That’s the first step. We need to rethink what it is that we’re doing and how we’re not taking them away from their treatment. Instead, we want oncologists to integrate palliative care early to provide a supportive environment for patients to talk about their feelings, to understand their pain, to understand what’s hurting for them, and to do that in a way that’s collaborative.

If oncologists recognize that they can turn to their local palliative care teams and say “look, I need help with this, this is really hard for me to have this discussion,” or in trying to manage a patient’s pain: “How can we collaborate together?” That barrier will start to diminish, and you’ll start to see more referrals and more excitement about getting palliative care involved.

What are some of the benefits of palliative care for the treating physician?

There actually have been some studies and some people looking at this. One study that I came across showed that palliative care actually increases oncology practices’ efficiency. If you’re a community oncologist or in a practice, you can be a lot more efficient in seeing more patients by having a palliative care team. By having someone else talk to patients about the pain issues, the symptom issues, some of the difficult conversations, it decreases the amount of time a physician spends in each visit.

We’ve also seen the benefits of the approach in terms of not providing aggressive, non-beneficial therapy at the end of life, such as being hospitalized, going to the ICU, things like that. A lot of oncologists suffer in this area. Also, the effects it has on the overall healthcare system, which we’re learning more and more about that even outpatient palliative care as well as inpatient palliative care can actually decrease hospitalization and readmissions to the hospital.