Thursday, November 29, 2012

Integrated palliative care is suddenly all the rage

Last year an article by Thoonsen et al noted that early (they use the term 'proactive') palliative care "has hardly been addressed in the scientific literature."  In 2012 there have been over a dozen papers (by my very informal and quick count) on this topic in both specialty (palliative care and oncology) and general medical journals.  Both European and US-based journals are represented.  They are an eclectic group, including retrospective studies, clinical trials, case studies, secondary analyses, and reviews.  Some form of the term 'integration' (integrated, integrative) is commonly used as an adjective.  Others seen are proactive, as noted above; concurrent; early or early access; prospective; comprehensive; and holistic.  The focus varies:  specific diagnoses (breast and lung cancer) vs general "advanced cancer;" specific symptoms (peripheral neuropathy and depression); outcomes (costs and hospice referrals); and comparisons of symptom burden in various ethnic groups.  A few of the papers noted that integrated palliative care benefits healthcare providers as well as patients and families.  Most papers cited Temel et al's 2010 NEJM study comparing standard care of newly diagnosed metastatic nonsmall cell lung cancer with standard care plus palliative care starting at diagnosis.  Most also cited culture change, resources, widespread misunderstandings about palliatiuve care, and a small evidence base as barriers to integration.

Last month I attended the excellent Eighth Annual Chicago Supportive Oncology Conference.  The overall theme of the first day was integrating palliative care with standard/usual cancer treatment.  Highlights for me included:

  • Deborah Dudgeon, MD, of Cancer Care Ontario (CCO) discussing the effort to both integrate palliative care and coordinate across multiple institutions.  A basic element is the use of computer kiosks in oncology waiting rooms in which patients enter their current symptom status using the Edmonton Symptom Assessment Scale.  Cancer Care Ontario has also developed symptom management and palliative care tools to encourage standardized approaches to care.
  • Toby Campbell, MD, is a medical oncologist and palliative care physician.  Wearing his palliative care hat, he sees patients jointly with thoracic oncologists.
  • Marie Bakitas, DNSc, of Norris Cotton Cancer Center (Dartmouth), discussed findings from the ENABLE series of studies of concurrent palliative care.  These studies have confirmed that early/concurrent palliative care does not shorten survival.  Among other things, they are also exploring what is in the "palliative care syringe:"  components and doses.
  • Ralph Hauke, MD, of Nebraska Cancer Specialists, discussed the ASCO Leadership Development Program in Palliative Care, identifying palliative care as "an integral component of oncology care and is underutilized throughout the continuum of care."  He described a Palliative Care Service Model that uses some of the same approaches and tools as CCO.
  • Tom Smith, MD, of Johns Hopkins, discussed the economics of integrated palliative care.  He advocated a palliative care approach as a way to "bend the cost curve" of exponentially increasing cancer care costs.
  • Susan Block, MD of Dana Farber, discussed the poorly-designed electronic medical record as a barrier to quality care, using the example of searching for an advance directive in a record that wasn't designed to note it, store it, or track it.  She went on to describe how Dana Farber redesigned part of the medical record to support patient and family communication and consistent recording of advance care planning.
One thought that came to me is that palliative care programs that are in the early stages of development should have integration as a high policy and structural priority--much easier than retrofitting.