News Review From Harvard Medical School -- Cancer Palliative Care Often Comes Late
Many cancer doctors refer their patients to palliative care only very late in the disease process, a study from Canada shows. The study was based on a survey of 603 oncologists. Most of the doctors practiced in hospitals that had access to palliative care. This is a type of care that focuses on pain relief and the overall well-being of patients and their families. It may include psychological, social and sometimes spiritual care. About one-third of oncologists said they referred patients for this type of care when they found that a cancer had spread. Such cancers often can be treated but not cured. Another one-third of the doctors said they waited to refer to palliative care until chemotherapy was stopped. This often occurred just a few weeks or months from death. Palliative care is designed to benefit patients throughout treatment, not just at the end. It is not the same as hospice care, which does focus on the end of life. The Journal of Clinical Oncology published the study. Reuters Health news service wrote about it October 29.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Not that long ago, doctors had little to offer very sick people other than some pain relief and comfort. They spent time helping the patient and family cope as the patient approached death. This was palliative care before anyone used that name.
Today, the focus of care is almost always geared to life-prolonging and often life-saving treatments. Doctors have much more to think about and much more they can do.
The effort to provide complex care for very ill patients is time-consuming. For example, a cancer specialist must coordinate chemotherapy, radiation and surgery. Using all of these treatments may give a patient the best chance of survival. But managing treatments leaves precious little time for other issues that all seriously ill patients and their families face.
Hospice care has helped to fill this need. But most often hospice teams have not become involved until it was clear that someone had a short time to live. Sometimes hospice care began just a couple of days before death.
Palliative care for anyone with a serious illness, regardless of the prognosis, is a fairly new concept. It has taken a couple of decades to gain traction.
Palliative care can go hand-in-hand with care that extends life or cures the illness. Rather than focusing on the disease, palliative care focuses on the patient. The main goals are to relieve physical and emotional suffering and to enhance the quality of life for patients and their families.
Palliative care is a specialty. Doctors can become "board certified" in the field. As with other specialties, the treating doctor needs to make a referral to the palliative care specialist. This doctor works with a team that typically includes a nurse and a social worker. There is often support from others as well. They may include a nutritionist, physical therapist, psychiatrist, pharmacist and chaplain.
We don't have a lot of information about doctors' referral patterns to palliative care. This new study comes from Canada. Researchers sent out surveys to cancer specialists in their country. The researchers were interested in:
- How the doctors viewed palliative care
- How they decided if and when to refer to palliative care
- Why they were reluctant to refer or why they waited so long
The survey responses suggested that most cancer specialists still viewed palliative care as similar to hospice. They tended to wait to refer patients to palliative care until the disease had spread or cancer therapy stopped working. Uncontrolled pain was often the reason for the referral. But palliative care also can help with anxiety, stress and family issues. These other factors were more likely to be missed if pain control was not a problem.
Interestingly, some cancer doctors were uncomfortable with the name "palliative care." They worried that patients referred to a service with this name would interpret the move as giving up. Instead, these doctors suggested the term "supportive care."
What Changes Can I Make Now?
Palliative care is indeed supportive care. It does not mean that other care stops. Palliative care can begin at any time during a serious illness. The goal is to help improve quality of life. It does not take the place of other active care, including chemotherapy. And it does not matter how long the person is expected to live.
Palliative care accomplishes this by:
- Focusing on emotional as well as physical needs
- Making the relief of pain and suffering a top priority
- Providing active support to loved ones and caregivers
Palliative care is best known for helping patients gain better pain relief. Here are some of the other times a palliative care team offers help:
- Distressing symptoms, such as marked fatigue, constipation or insomnia
- Family concerns about how to take care of someone who is at home or going home from the hospital
- Questions about what is going on with a patient that don't seem to have clear answers
What Can I Expect Looking to the Future?
In this study, younger cancer doctors and those who spent time on a palliative care service during their cancer training were more likely to refer to palliative care. And they made the referrals earlier.
It has taken time for people to find out how much hospice care offers for dying patients and their families. In the near future, I expect people will begin to understand and appreciate the place for palliative care as well.