Tuesday, February 9, 2016

The New World of Outpatient Palliative Care

by Kimberly Curseen

As the field of palliative medicine expands much attention and resources have been placed on inpatient consultation, with very positive results for patients and the health care system. We can now see access to inpatient palliative care is becoming a standard. The natural progression is to then extend the same important resource to patients in the outpatient setting. Outpatient palliative care provides resources for symptom management for patients and families going through aggressive and maintenance treatments for their serious illness.

Studies for the last decade have been demonstrating the effectiveness of early palliative care in improving patient quality of life and reduction in acute care resource utilization at end of life. Although results of the impact of outpatient palliative care may vary in the literature, it is consistent that these programs improve aspects of quality of life that patients consider to be important.

The Temel study in the New England Journal of Medicine "Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer" is one of the most cited studies showing the impact that early longitudinal palliative care can have on patient's quality of life. Patients were randomized to integrated palliative care with oncology care vs standard oncology care. The early palliative care intervention resulted in improved quality of life and mood in addition to less aggressive care at end of life and possibly prolonged survival for patient receiving the intervention.

A study in Archives of Internal Medicine in 2004 "The Comprehensive Care Team: A Controlled Trial of Outpatient Palliative Medicine Consultation" showed improve outcomes in spiritual distress and dyspnea but not in pain or depression. Another study in the Journal of Palliative Medicine in 2012 "The Impact of an Outpatient Palliative Care Consultation on Symptom Burden in Advanced Prostate Cancer Patients" showed that in their preliminary data patients had improvement in pain, drowsiness, fatigue, depression, sleep, sense of well-being, and anxiety.

In 2013 the Journal of Palliative Medicine published "Moving Upstream: A Review of the Evidence of the Impact of Outpatient Palliative Care" which reviewed the current literature up to that point on the impact of outpatient programs. The evidence supported that outpatient palliative care could "...1) improve patient satisfaction, 2) improve symptom control and quality of life, 3) reduce health care utilization, and 4) lengthen survival in a population of lung cancer patients".

With a growing body of literature supporting the need for outpatient palliative care, in addition to other health professions accepting that earlier integration of these services is important for patients, we as a profession are continuing to discuss how best to meet this growing need. Outpatient palliative care poses a variety of challenges for sustainability. Some of these include:

  • What defines outpatient palliative care? What are the core team members that must be available to patients to be an outpatient palliative care clinic?
  • How does a clinic continue to financially support non-billing members of a team?
  • Does the team assume primary symptom management or write recommendations?
  • What is our role in complex opioid management?
  • Should outpatient palliative care providers have training in addiction medicine?
  • Do patients transition out of outpatient palliative care?
  • How do we interface with primary care providers? Are we the primary providers for the seriously ill?
  • Who qualifies for outpatient palliative care? What defines a "serious illness"?
  • Should clinics be embedded in specific specialty ie oncology, geriatrics, cardiology etc or stand alone?
  • What guidelines are we following for symptom management? Could a patient move around the country and receive the same standard of care from clinic to clinic?
  • Are our fellows adequately trained to assume non-academic outpatient palliative care positions?
Practicing outpatient palliative care has been the most rewarding work of my life and I cannot imagine doing anything else. However, I find myself often concerned with whether my clinic is providing the standard of care our patients deserve. I find myself often with faced with challenging questions about how to deliver effective care with limited resources in addition how to protect these resources in fiscally troubled times. This year at the AAHPM annual meeting in Chicago several members will be attending as exploratory to meeting to develop an Outpatient Palliative Care SIG. I am hoping that it will help develop a network for Outpatient providers to share the challenges and solutions to issues that many of us are facing. (If you are a AAHPM member see AAHPM Connect for more info.)

Please join us for #HPM tweetchat to discuss this very important topic Feb 10th at 9:00pm.

T1: What defines an outpatient palliative care? Is a single provider enough?
T2: What are the challenges to sustainability of outpatient palliative care clinics?
T3: Should outpatient palliative care providers be trained in addiction medicine?

Dr. Kimberly Curseen is an outpatient palliative and geriatrician doc in Georgia working to advance access to quality palliative care for people with serious illness. 

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 2/10/2015 - 9p ET/ 6p PT
Host: Dr. Kimberly Curseen

 for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org


Michael R et al. The Comprehensive Care Team A: Controlled Trial of Outpatient Palliative Medicine Consultation. Arch Intern Med 2004; 164(1): 83-91 OPEN ACCESS PDF

Michael R et al. Moving Upstream: A Review of the Evidence of the Impact of Outpatient Palliative Care. Journal of Palliative Care Medicine. 2013, 16(12): 1540-1549

Temel J et al. Early Palliative Care for Patient with Metastatic Non-Small Cell Lung Cancer. N Engl J Med 2010; 363:733-742 OPEN ACCESS PDF

Yennurajalingam S et al. The Impact of an Outpatient Palliative Care Consultation on Symtpom Burden in Advanced Prostate Cancer Patients. Journal Of Palliative Medicine 2012; 15(1): 20-24 NOT OPEN ACCESS

Image Credit: Outpatients via www.tamesidehospital.nhs.uk. All Rights Reserved
Image Credit: #hpm square by Christian Sinclair for Pallimed. CC BY 2.0

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