In response to new evidence regarding the benefits of palliative care for patients with advanced cancer, and in recognition of the very real challenges physicians face when trying to broach the topic with patients, ASCO released a policy statement yesterday to help guide physicians through these difficult conversations. In addition, they announced plans to issue clinical guidance later this year to further help physicians initiate these conversations and integrate palliative care into oncology practice.
The core principles of the recommendations are:
- Physicians should initiate candid discussions about prognosis with their patients soon after an advanced cancer diagnosis. Such conversations currently occur with less than 40% of patients with advanced cancer.
- Quality of life should be an explicit priority throughout the course of advanced cancer care. Physicians must help their patients fully understand their prognosis, the potential risks and benefits of available cancer treatments, and quality of life considerations. In cases where active treatment is unlikely to extend survival, palliative care should be discussed as a concurrent or alternate therapy.
- Clinical trial opportunities should be increased. Currently, very few patients with advanced cancer participate in trials due to strict eligibility criteria, a dearth of trials that address quality of life issues, and other barriers. Increasing opportunities for these patients to potentially benefit from trials and to contribute to improving cancer care should be a high priority.
ASCO Issues Recommendations for Discussing End-of-Life Care
Increasingly, community-based cancer programs are seeking to provide a more coordinated, multidisciplinary care experience to their patients. There are a few factors driving this trend, both clinical and market-oriented, as clinics provide the opportunity to improve outcomes and provide a more patient-centered experience, as well as serve as potential mechanism to achieve market differentiation. Multidisciplinary clinics have long been at the core of academic cancer care, but we've been receiving a lot of questions about executing on the concept at community hospitals. Those programs working with multiple groups of private practice physicians, or a mix of employed and private practices physicians often encounter a number of obstacles when seeking to implement multidisciplinary clinics. Below I've listed out the most common issues. At the end of this post I've included links to our most recent research which addresses many of these issues.
Addressing economic inefficiency - or making it worth their while
Private practice physicians are already incredibly busy, never more so than now as they are under increasing financial pressure, and quite frankly, these clinics are often not that efficient - often there is a lot of down time. During the time it takes for one clinic in which they might see 3 patients, they can often see twice as many in their office. There are ways to address this issue. First, is to guarantee payment for their time to ensure they don't lose out financially. Another option is to try to optimize efficiency via the "virtual clinic" concept in which the patient might see all of the relevant physicians in their own office in a short period of time (a week for instance) and then they'd discuss the patient at a weekly conference. In these sorts of models a care coordinator or patient navigator is essential to make sure all of the moving parts come together as planned.
The challenge of establishing multidisciplinary clinics in a "mixed" environment
Yesterday I had the opportunity to participate in an excellent webcast sponsored by the Center to Advance Palliative Care (CAPC) and presented by Dr. David Weissman, professor emeritus from the Medical College of Wisconsin. Dr. Weissman discussed the potential to use consult triggers (i.e. objective patient- or disease-specific criteria) to help increase referrals for pallaitive care consults and increase the likelikhood that they are made in a timely way. Triggers may include disease variables such as a diagnosis of metstatic cancer or stage IV CHF, or patient variables such as two or more hospitalizations during a one month period or an ICU stay of longer than X days.
In the presentation, Dr. Weissman outlined five key steps for successful implementation:
- Define your goals. Hospitals may want to use consult triggers to increase referrals to palliative care, meet unmet patient needs or achieve specific institutional goals such as cost reduction. It's important to define these goals upfront and determine how the organization will measure progress against them.
- Evaluate staffing needs. In most cases, consult triggers will result in increased referrals to the pallaitive care team. Consequently hospitals must forecast this change and ensure that their pallaitive care team is staffed to manage the growth.
Five Steps for Developing Palliative Care Consult Triggers