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Tuesday, May 28, 2013

Palliative Care Triggers for Oncology

I read the ASCO Post when I’m on airplanes.  At least I do, below 10,000 feet… and after I have finished the Sudoku.

The ASCO Post is the People magazine of oncology.  The articles are short… typically one page, with lots of pictures consisting mostly of the authors.  It is medical journal lite, with terms and prose simple enough for a layman to both understand and to not fall asleep by the end of the article.  It probably can be best described as Oncology for Dummies.
(Also, to give the full extent of its look and feel… there is usually one or two ads attached with that gooey stuff you try to pull off the paper, but the kind that usually snaps back and hits you in the eye.)
In any event, the May 1st issue featured an article on access to care. The title suggested it was about patient access to oncologic care, depending on geographic and economic factors. That was a focus, but I’m glad I kept reading to see that it wasn’t the only focus. The last section of the article was titled, “Missed Opportunities for End-of-life Care?”  If I hadn’t kept reading, it definitely would have been a missed opportunity for me.
The article summarized a manuscript in the Journal of Oncology Practice authored by Gabrielle B. Rocque, MD and her colleagues. This group analyzed data from their institutions and determined that an unscheduled hospitalization for a patient with advanced cancer, “strongly predicts survival of fewer than 6 months.” Wow. Not surprisingly, the authors recommended a palliative care consultation as a potential intervention for this group of patients.
When I worked at CIGNA many years ago, there was a training program known fondly as “bing-bong school.”  It was an internal training course for licensure exams. The idea was to train students that a key word in a test question should lead to a mental “bing-bong,” that would trigger the correct answer.  Kind of like the answer to any question about American history is, “manifest destiny.”
So, I wondered if this manuscript wouldn’t suggest a “bing-bong” opportunity in community oncology practice. Should a palliative care intervention be part of the automatic response?  A hypothesis could be that most medical oncology admissions are unscheduled or unexpected, but not all.  Would there be some obvious patients to exclude? An oncologist colleague and I pondered this and thought that most admissions would have a substantial symptom-related component, so that if we could keep the focus more on the palliative side than the hospice side, we may ease some apprehensions, and lower barriers.
We thought we might exclude two populations from “bing-bong” interventions…  Patients receiving adjuvant therapy who were being admitted for neutropenic fever, which might be asking an awful lot of oncologists, to even have a wisp of hospice near these patients, and is outside of the guidance from Rocque et al. And, patients on BMT regimens may arguably benefit from palliative care interventions, but one would hope and perhaps expect, that such interventions would be a part of the continuum of care for those patients well before the admission stage. The focus could probably be on lower hanging fruit.  
We landed on a proposed idea that any admission of an oncology patient with metastatic disease ought to have a palliative care intervention. We felt that could be a fair straw man…a starting point.
But then I wondered if that really is a starting point, or a start of an endpoint.  In an article we co-authored, my friend Karen Porter-Williamson wrote that too often the inpatient hospice team is the “stop team,” only called in when all else fails. If that is the case at a hospital, it seems that the palliative intervention probably wouldn’t yield great results. My sense is that Rocque and colleagues, as well Porter-Williamson and her team, would see this as an opportunity to start a conversation that extends beyond discharge, and allows the development of a concurrent care path in the outpatient setting, in parallel with continued care by the oncologist.
I think there are places where this could happen, but many places where it could not.  Where an adequate or strong inpatient palliative care team may exist, perhaps the outpatient side does not. Or perhaps there is an outpatient partner, but the logo on the name tag says “hospice” on it.  Or, perhaps there are no true partners, but an array of options on a referral list.
While I think there may be an ability to distill a “bing-bong” moment with the inpatient oncology patient, our opportunity to enhance care will only be realized if the inpatient intervention is the beginning of the journey in palliative care.  A “one and done” approach might make us feel like we have achieved something, and maybe moved the board pieces a little closer to the end game of accreditation, but the patient and family truly win only if the intervention evolves into a long-term engagement.
John Hennessy is Vice President, Operations for Sarah Cannon, the global cancer enterprise of Hospital Corporation of America (HCA). His focus areas at Sarah Cannon are medical oncology, survivorship, and palliative care.  He serves on the Board of Trustees of the Association of Community Cancer Centers (ACCC), and on several committees for the American Society for Clinical Oncology (ASCO), including the Clinical Practice Committee.  
Bath, C:  Access to Care:  Who Gets Referred to a Medical Oncologist and/or Another Cancer Specialist and Who Receives Treatment for Advanced Cancer?  The ASCO Post, Volume 4, Issue 7 2013
Rocque GB, Barnett AE, Illig LC, et al: Inpatient hospitalization of oncology patients: Are we missing an opportunity for end-of-life care? J Oncol Pract 9:51-54, 2013.
Hennessy J, Lown B, Landzaat L, Porter-Williamson K:  Practical Issues in Palliative and Quality-of-Life Care  J Oncol Pract 9:2 78-80, 2013
Photo Credit: "baby's first homemade ornament" by Darwin Bell - Some Rights Reserved

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