Article

Toward Palliative Care for All Patients With Advanced Cancer

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Abstract

A recently updated clinical practice guideline from the American Society of Clinical Oncology (ASCO) strongly recommends that all patients with advanced cancer receive palliative care early in the disease course, concurrent with active treatment.¹ We applaud this recognition that the pillars of palliative care—including assessment and treatment of distressing symptoms, exploration of illness understanding and prognostic awareness, clarification of treatment goals, and assistance with decision making—should be the standard of care. Over the past 10 years, a growing evidence base has demonstrated the value of these services in promoting quality of life for patients with advanced cancer.² The most recent ASCO guidelines build on reports from the Institute of Medicine and previous ASCO consensus statements defining palliative care as an integral part of oncology.

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... 1,2 Yet, national trends have, until now, shown that many eligible patients may not be receiving palliative care services until very late stages of illness, or at all. 3,4 In this brief report, we retrospectively examined the trends over time of palliative care consultations among patients with advanced cancer who received palliative radiation therapy (PRT) in our health system. PRT is a commonly used palliative intervention among advanced cancer patients and is an important part of multidisciplinary supportive oncology care and physical symptom management. ...
... Literature suggests that access to palliative care tends to be greater for patients living in urban settings compared to those in rural settings, because of proximity to large medical centers and greater availability of palliative care resources. 3,4,18 Palliative care services are still not as well integrated in the community setting due to a shortage of palliative care specialists in the outpatient setting. 3 A push for utilization of outpatient palliative care specialty clinics, with standardized criteria to streamline outpatient referrals, may help address this discrepancy. ...
... 3,4,18 Palliative care services are still not as well integrated in the community setting due to a shortage of palliative care specialists in the outpatient setting. 3 A push for utilization of outpatient palliative care specialty clinics, with standardized criteria to streamline outpatient referrals, may help address this discrepancy. 22 Third, our study did not examine the subsequent rates of palliative care involvement beyond the first consultation. ...
Article
Context: The American Society of Clinical Oncology recommends that all patients with metastatic disease receive dedicated palliative care (PC) services early in their illness, ideally via interdisciplinary care teams. Objectives: We investigated the time trends of specialty palliative care consultations from the date of metastatic cancer diagnosis among patients receiving palliative radiation therapy (PRT). A shorter time interval between metastatic diagnosis and first PC consultation suggests earlier involvement of palliative care in a patient's life with metastatic cancer. Methods: In this IRB-approved retrospective analysis, patients treated with PRT for solid tumors (bone and brain) at a single tertiary care hospital between 2010 and 2016 were included. Cohorts were arbitrarily established by metastatic diagnosis within approximately two-year intervals: (1) 1/1/2010-3/27/2012; (2) 3/28/2012-5/21/2014; and (3) 5/22/2014-12/31/2016. Cox-proportional hazards regression modelling was used to compare trends of PC consultation among cohorts. Results: Of 284 patients identified, 184 patients received PC consultation, whereas 15 patients died before receiving a PC consult. Median follow-up time until an event or censor was 257 days (range: 1,900). Patients in the most recent cohort had a shorter median time to first PC consult (57 days) compared to those in the first (374 days) and second (186 days) cohorts. On multivariable analysis, patients in the third cohort were more likely to undergo a PC consultation earlier in their metastatic illness (HR: 1.8, 95% CI: 1.2,2.8). Conclusion: Over a six-year period, palliative care consultation occurred earlier for metastatic patients treated with PRT at our institution.
... Moreover, our findings highlight the potential benefit and promise of integrating palliative/supportive cancer care services into routine oncology care. Approaches for integrating such services into routine care include specialty palliative care provided by palliative medicine specialists and primary palliative care provided directly to patients by oncologists and oncology nurses [35,36,42]. Because palliative medicine specialists are well versed in the array of symptoms experienced by cancer patients, specialty palliative care teams are well positioned to address patient questions regarding potential and current symptoms and offer recommendations for alleviating symptoms. ...
... Because palliative medicine specialists are well versed in the array of symptoms experienced by cancer patients, specialty palliative care teams are well positioned to address patient questions regarding potential and current symptoms and offer recommendations for alleviating symptoms. However, there is currently a shortage in the supply of palliative medicine specialists relative to the potential demand among cancer patients, making equitable access and coordination a challenge [42]. As care fragmentation is more commonly reported among patients of color and linked to lower care utilization and worse care outcomes [43][44][45], integrating palliative/supportive cancer care services into routine care through primary palliative care may help promote equity in the coordination and delivery symptom management of symptom management services [35]. ...
Article
Full-text available
PurposeRacial disparities in cancer treatment-related symptom burden are well documented and linked to worse treatment outcomes. Yet, little is known about racial differences in patients’ treatment-related symptom management experiences. Such understanding can help identify modifiable drivers of symptom burden inequities. As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, we examined racial differences in symptom management experiences among Black and White breast cancer survivors (BCS). Methods We conducted six focus groups (n = 3 Black BCS groups; n = 3 White BCS groups) with 22 stages I–IV BCS at two cancer centers. Focus groups were audio-recorded and transcribed verbatim. Based on key community-based participatory research principles, our community/academic/medical partner team facilitated focus groups and conducted qualitative analyses. ResultsAll BCS described positive symptom management experiences, including clinician attentiveness to symptom concerns and clinician recommendations for pre-emptively managing symptoms. Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians’ failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS often described dissatisfaction regarding inadequate information on symptom origins and clinicians’ failure to offer reassurance. Conclusions This study elucidates opportunities for future research aimed at improving equity for cancer treatment-related symptom management. For Black women, warnings about anticipated symptoms and treatment for ongoing symptoms were particular areas of concern. Routine symptom assessment for all women, as well as clinicians’ management of symptoms for racially diverse cancer patients, need to be more thoroughly studied and addressed.
... Given significant shortages of palliative care specialists, strategies to improve provision of 'primary' palliative care by non-specialists are needed [1,2]. CONNECT (Care management by Oncology Nurses to address supportive care needs) is an oncology nurse-led care management intervention designed to strengthen provision of 'primary' palliative care within oncology practices (3). ...
... Notably, these trials used interventionists with specialty palliative care training. With increasing focus on the need for evidencebased 'primary' palliative care models, rigorous yet pragmatic strategies for (1) identifying and training interventionists and (2) monitoring and maintaining intervention fidelity are needed. A recent systematic review concluded that, to date, implementation fidelity in palliative care is under-recognized [13]. ...
Article
Full-text available
Context Intervention fidelity is a critical component of behavioral research that has received inadequate attention in palliative care studies. With increasing focus on the need for palliative care models that can be widely disseminated and delivered by non-specialists, rigorous yet pragmatic strategies for training interventionists and maintaining intervention fidelity are needed. Objectives (1) Describe components of a plan for interventionist training and monitoring and maintaining intervention fidelity as part of a primary palliative care trial (CONNECT) and (2) present data about perceived training effectiveness and delivery of key intervention content. Methods Post-training evaluations, visit checklists, and visit audio-recordings. Results Data were collected from June, 2016 through April, 2017. We include procedures for (1) identification, training and certification of oncology nurses as CONNECT interventionists; (2) monitoring intervention delivery; and (3) maintaining intervention quality. All nurses (N = 14) felt prepared to deliver key competencies after a 3-day in-person training. As assessed via visit checklists, interventionists delivered an average of 94% (SD 13%) of key content for first intervention visits and 85% (SD 14%) for subsequent visits. As assessed via audio-recordings, interventionists delivered an average of 85% (SD 8%) of key content for initial visits and 85% (SD 12%) for subsequent visits. Conclusion We present a 3-part strategy for training interventionists and monitoring and maintaining intervention delivery in a primary palliative care trial. Training was effective in having nurses feel prepared to deliver primary palliative care skills. As assessed via nursing checklists and visit audio-recordings, intervention fidelity was high.
... Hence, the focus of oral healthcare providers is to manage symptoms and maximize quality of life during the end-of-life transition. The American Society of Clinical Oncology (ASCO), in a recently updated clinical practice guideline, strongly recommends that palliative care be provided to all patients with advanced cancer early in the disease course, at the same time as active treatment [1]. Wiseman [2] advocated that symptom relief was the primary principle of palliative care dentistry, which focused on treatment of terminally ill patients in whom the oral cavity was affected directly or indirectly by the illness. ...
... Oral Hygiene Maintenance Strategies in Palliative Care.1. Encouragement and reinforcement of good oral hygiene maintenance 2. Tooth brushing twice daily and after meals with a soft to medium toothbrush, ...
... In agreement with Schenker and Arnold [18,38,39], to improve PC for patients with chronic illness, we used specific training to develop I-level PC skills in HPs to improve the quality of care in hospital. Our results are in agreement with other studies that were also applied in non-oncological settings, for example, those obtained by Hepgul et al. [7], which emphasized that the collaboration between neurologists and palliative care professionals has a positive overall impact on the management of patients with progressive neurological disorders. ...
Article
Full-text available
Background: Despite the great advances in the concept of palliative care (PC) and its benefits, its application seems to be delayed, leaving unfulfilled the many needs of patients and family members. One way to overcome this difficulty could be to develop a new training programme by palliative care specialists to improve PC primary skills in healthcare professionals. The aim of this study was to evaluate the training's impact on trainees within a hospital setting using Kirkpatrick's and Moore's models. Methods: We adopted a mixed-method evaluation with concurrent triangulation. The evaluation followed the first three steps of Kirkpatrick's and Moore's models and included a pre- and post-training evaluation through self-administered questionnaires and focus groups. We used the McNemar statistical test. Results: The results highlighted the significant amount of knowledge acquired by the hospital professionals after training, in terms of increasing their knowledge of palliative care and in terms of the change in meaning that they attributed to phenomena related to chronicity and incurability, which they encounter daily in their professional practice. In both quantitative and qualitative research, the results, in synthesis, highlight: (i) the development of a new concept of palliative care, centred on the response to the holistic needs of people; (ii) that palliative care can also be extended to non-oncological patients in advanced illness stages (our training was directed to Geriatrics and Nephrology/Dialysis professionals); (iii) the empowerment and the increase in self-esteem that healthcare professionals gained, from learning about the logistical and structural organization of palliative care, to activate and implement PC; (iv) the need to share personal aspects of their professional life (this result emerges only in qualitative research); (v) the appreciation of cooperation and the joining of multiple competences towards a synergistic approach and enhanced outcomes. Conclusion: It is necessary to further develop rigorous research on training evaluation, at the most complex orders of the Kirkpatrick and Moore models, to measure primary PC skills in health care professionals. This will develop the effectiveness of the integration of I- and II-level palliative care competencies in hospitals and improve outcomes of patients' and families' quality of life.
... Another area where an RO can play a key role in patient management is palliative care and symptom management. [5][6][7] Establishment of the Society for Palliative Radiation Oncology was a symbolic step to enhance RO training in palliative care, but membership currently comprises approximately 130 residents and attending physicians of the American Society for Radiation Oncology's more than 10,000 members. Radiation oncology also is one of only six Accreditation Council for Graduate Medical Educationrecognized specialties that can sponsor the American Academy of Hospice and Palliative Medicine's hospice and palliative medicine fellowship program. ...
... This is particularly relevant to pancreatic cancer, which has exceptionally high mortality and morbidity. Palliative care, when provided in parallel with antineoplastic therapies, can lead to improved cancer outcomes including improved OS and quality of life (5)(6)(7)(8)(9). Especially if offered early in the disease course, palliative care can lead to less aggressive interventions near the end of life (6). ...
Article
Full-text available
Background: Palliative care has been associated with improved survival and quality of life, with lower rate of end-of-life health care utilization and cost. We examined trends in palliative care utilization in older pancreatic cancer patients. Methods: Pancreatic cancer patients with and without palliative care consults were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database between 2000 and 2009. Trend of palliative care use was studied. Emergency room/intensive care unit (ICU) utilization and costs in the last 30 days of life were compared between both groups using propensity score-matched (PSM) analysis. Results: Of the 54,130 patients, 3,166 (5.8%) received palliative care and 70% received it in the last 30 days of life. The proportion of patients receiving palliative care increased from 1.4% in 2000 to 7.4% in 2009 (P<0.001). Patients with palliative care were more likely to be older, Asian and women. In the unmatched and PSM population, the average visits to the ER in the last 30 days of life were significantly higher for patients who received palliative care, and had a significantly higher cost of care. Similarly, ICU length of stay in the last 30 days of life was higher in patients who did not receive palliative care in both PSM and unmatched patients. Cost of care and number of ICU admissions were not different between palliative and non-palliative care groups in PSM and unmatched patients. Conclusions: In this study of Medicare patients with pancreatic cancer, palliative care use has increased between 2000 and 2009. Palliative care was largely offered close to the end of life and was not associated with reduced health care utilization or cost.
... This is clearly not the case in the UK and whilst there may be very little overlap in the US, this is due to the way reimbursements provided by insurance companies structure clinical practice, something that is increasingly seen as highly problematic (cf. [35]). 5 Reviewing this article, Dr. Michael Connoly points out that whilst Cicely Saunders founded the modern hospice movement, this was foreshadowed by the work of the Irish Religious Sisters of Charity in the late 1800s and, in the early 1900s, by St Joseph's Hospice in London. ...
Article
Full-text available
Background: Making particular use of Shale's analysis, this paper discusses the notion of leadership in the context of palliative medicine. Whilst offering a critical perspective, I build on the philosophy of palliative care offered by Randall and Downie and suggest that the normative structure of this medical speciality has certain distinctive features, particularly when compared to that of medicine more generally. I discuss this in terms of palliative medicine's distinctive morality or ethos, albeit one that should still be seen in terms of medical morality or the ethos of medicine. Main text: I argue that, in the context of multi-disciplinary teamwork, the particular ethos of palliative medicine means that healthcare professionals who work within this speciality are presented with distinct opportunities for leadership and the dissemination of the moral and ethical norms that guide their practice. I expand on the nature of this opportunity by further engaging with Shale's work on leadership in medicine, and by more fully articulating the notion of moral ethos in medicine and its relation to the more formal notion of medical ethics. Finally, and with reference to the idea of medical education as both on going and as an apprenticeship, I suggest that moral and ethical leadership in palliative medicine may have an inherently educational quality and a distinctively pedagogical dimension. Conclusions: The nature of palliative medicine is such that it often involves caring for patients who are still receiving treatment from other specialists. Whilst this can create tension, it also provides an opportunity for palliative care professionals to disseminate the philosophy that underpins their practice, and to offer leadership with regard to the moral and ethical challenges that arise in the context of End of Life Care.
... Thus, there appears to be more room for improvement. Because palliative care does not have the infrastructure to see all patients with advanced cancer [20], implementation of standardized criteria to identify patients who would be most likely to benefit from a palliative care intervention coupled with automatic referral may improve the consistency of the referral process. A recent Delphi study involving 60 international experts achieved a high level of consensus for 11 major criteria to trigger outpatient palliative care referral [21]. ...
Article
Background: There is significant variation in access to palliative care. We examined the pattern of outpatient palliative care referral among thoracic medical oncologists and identified oncologist characteristics associated with greater referral. Materials and methods: We retrieved data on all patients who died of advanced thoracic malignancies at our institution between January 1, 2007, and December 31, 2012. Using median as a cutoff, we defined two groups (high-referring and low-referring oncologists) based on their frequency of referral. We examined various oncologist- and patient-related characteristics associated with outpatient referral. Results: Of 1,642 decedents, 444 (27%) had an outpatient palliative care referral. The median proportion of referral among 26 thoracic oncologists was 30% (range 9%-45%; median proportion of high-referring 37% vs. low-referring 24% when divided into two groups at median). High-referring oncologists were significantly younger (age 45 vs. 56) than low-referring oncologists; they were also significantly more likely to refer patients earlier (median interval between oncology consultation and palliative care consultation 90 days vs. 170 days) and to refer those without metastatic disease (7% vs. 2%). In multivariable mixed-effect logistic regression, younger oncologists (odds ratio [OR] = 0.97 per year increase, 95% confidence interval [CI] 0.95-0.995), younger patients (OR = 0.98 per year increase, 95% CI 0.97-0.99), and nonmetastatic disease status (OR = 0.48, 95% CI 0.29-0.78) were significantly associated with outpatient palliative care referral. Conclusion: The pattern of referral to outpatient palliative care varied widely among thoracic oncologists. Younger oncologists were not only referring a higher proportion of patients, but also referring patients earlier in the disease trajectory. Implications for practice: This retrospective cohort study found that younger thoracic medical oncologists were significantly more likely to refer patients to outpatient palliative care and to do so earlier in the disease trajectory compared with older oncologists, even after adjusting for other known predictors such as patient demographics. The findings highlight the role of education to standardize palliative care access and imply that outpatient palliative care referral is likely to continue to increase with a shifting oncology workforce.
... Within these diverse, highly vulnerable groups, the lack of access to palliative and hospice care is evident, as is the lack of research that would create palliative care programs that meet the unique needs of each of these groups. If we as a society are indeed committed to providing palliative care to all individuals diagnosed with cancer, 137,138 we need to initiate, develop, and implement: 1) policies that reduce barriers to palliative and hospice care for these groups; 2) systems that may not conform to the current medical care model; 3) other ways of delivering palliative care in rural areas, such as through telehealth or the training of local physicians and nurse practitioners in primary palliative care; 4) collaborative partnerships with unique groups to develop palliative care programs that meet their unique needs; and 5) creation of an inclusive hospice and palliative care environment so that all groups are welcomed. These efforts should include cultural diversity and sensitivity training programs for all palliative care professionals, as well as hiring of diverse staff or lay health advisors who have a deep understanding of the population being cared for. ...
Article
Full-text available
Objectives: To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer. Data sources: Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer. Conclusion: Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care. Implications for nursing practice: Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.
... Many contemporary RCTs involved specialist palliative care referral within 3 months of diagnosis of advanced cancer regardless of symptom burden; however, this model of care is currently infeasible given the limited palliative care infrastructure internationally. 67,68 Furthermore, some patients with advanced cancer may have limited supportive care needs around the time of diagnosis and may not require palliative care. Thus, instead of early palliative care for all, we advocate for timely palliative care, selecting the One approach to determining the right time involves a Delphi consensus. ...
Article
Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state‐of‐the‐science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team‐based, timely, and targeted palliative care. Team‐based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse‐led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00‐00. 2018 American Cancer Society, Inc.
... Due to the scarcity of palliative care resources, it is not possible to provide early palliative care for all patients with advanced disease from around the time of diagnosis [30]. Moreover, some patients may not require specialist palliative care initially due to low supportive care needs or their needs have been adequately addressed by the oncology team. ...
Article
Full-text available
Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.
... However, with the increasing therapeutic progresses made in oncology [20], the duration of advanced phase of oncologic diseases increases. Palliative care resources being limited and variable across countries [21,22],, patients should be referred to PCT at the right time and for the good reasons. These remain to be defined pragmatically, taking into account assessment of patients' needs and local resources of care [23,24]., ...
Article
Full-text available
Background: Palliative care (PC) referral is recommended early in the course of advanced cancer. This study aims to describe, in an integrated onco-palliative care program (IOPC), patient's profile when first referred to this program, timing of this referral and its impact on the trajectory of care at end-of-life. Methods: The IOPC combined the weekly onco-palliative meeting (OPM) dedicated to patients with incurable cancer, and/or the clinical evaluation by the PC team. Oncologists can refer to the multidisciplinary board of the OPM the patients for whom goals and organization of care need to be discussed. We analyzed all patients first referred at OPM in 2011-2013. We defined the index of precocity (IP), as the ratio of the time from first referral to death by the time from diagnosis of incurability to death, ranging from 0 (late referral) to 1 (early referral). Results: Of the 416 patients included, 57% presented with lung, urothelial cancers, or sarcoma. At first referral to IOPC, 76% were receiving antitumoral treatment, 63% were outpatients, 56% had a performance status ≤2 and 46% had a serum albumin level > 35 g/l. The median [1st-3rd quartile] IP was 0.39 [0.16-0.72], ranging between 0.53 [0.20-0.79] (earliest referral, i.e. close to diagnosis of incurability, for lung cancer) to 0.16 [0.07-0.56] (latest referral, i.e. close to death relatively to length of metastatic disease, for prostate cancer). Among 367 decedents, 42 (13%) received antitumoral treatment within 14 days before death, and 157 (43%) died in PC units. Conclusions: The IOPC is an effective organization to enable early integration of PC and decrease aggressiveness of care near the end-of life. The IP is a useful tool to model the timing of referral to IOPC, while taking into account each cancer types and therapeutic advances.
... However, with the increasing therapeutic progresses made in oncology (20) , the duration of advanced phase of oncologic diseases increases. Palliative care resources being limited and variable across countries (21), (22) , patients should be referred to PCT at the right time and for the good reasons. ...
Preprint
Full-text available
Background: Palliative care (PC) referral is recommended early in the course of advanced cancer. This study aims to describe, in an integrated onco-palliative care program (IOPC), patient’s profile when first referred to this program, timing of this referral and its impact on the trajectory of care at end-of-life. Patients and Methods: The IOPC combined the weekly onco-palliative meeting (OPM) dedicated to patients with incurable cancer, and/or the clinical evaluation by the PC team. Oncologists can refer to the multidisciplinary board of the OPM the patients for whom goals and organization of care need to be discussed. We analyzed all patients first referred at OPM in 2011-2013. We defined the index of precocity (IP), as the ratio of the time from first referral to death by the time from diagnosis of incurability to death, ranging from 0 (late referral) to 1 (early referral). Results: Of the 416 patients included, 57% presented with lung, urothelial cancers, or sarcoma. At first referral to IOPC, 76% were receiving antitumoral treatment, 63% were outpatients, 56% had a performance status ≤2 and 46% had a serum albumin level >35g/l. The median [1st-3rd quartile] IP was 0.39 [0.16-0.72], ranging between 0.53 [0.20-0.79] (earliest referral, i.e. close to diagnosis of incurability, for lung cancer) to 0.16 [0.07-0.56] (latest referral, i.e. close to death relatively to length of metastatic disease, for prostate cancer). Among 367 decedents, 42 (13%) received antitumoral treatment within 14 days before death, and 157 (43%) died in PC units. Conclusions: The IOPC is an effective organization to enable early integration of PC and decrease aggressiveness of care near the end-of life. The IP is a useful tool to model the timing of referral to IOPC, while taking into account each cancer types and therapeutic advances.
... In agreement with Schenker and Arnold [18,38,39], to improve PC for patients with chronic illness, we used specific training to develop I-level PC skills in HPs to improve the quality of care in hospital. Our results are in agreement with other studies that were also applied in non-oncological settings, for example, those obtained by Hepgul et al. [7], which emphasized that the collaboration between neurologists and palliative care professionals has a positive overall impact on the management of patients with progressive neurological disorders. ...
Preprint
Full-text available
Background: Despite the great advances in the concept of palliative care (PC) and its benefits, its application seems to be delayed, leaving unfulfilled the many needs of patients and family members. One way to overcome this difficulty could be to develop a new training programme by palliative care specialists to improve PC primary skills in healthcare professionals. The aim of this study was to evaluate the training's impact on trainees within a hospital setting using Kirkpatrick’s and Moore's models. Methods: We adopted a mixed-method evaluation with concurrent triangulation. The evaluation followed the first three steps of Kirkpatrick’s and Moore’s models and included a pre- and post-training evaluation through self-administered questionnaires and focus groups. We used the McNemar statistical test. Results: The results highlighted the significant amount of knowledge acquired by the hospital professionals after training, in terms of increasing their knowledge of palliative care and in terms of the change in meaning that they attributed to phenomena related to chronicity and incurability, which they encounter daily in their professional practice. In both quantitative and qualitative research, the results, in synthesis, highlight:the development of a new concept of palliative care, centred on the response to the holistic needs of people; that palliative care can also be extended to non-oncological patients in advanced illness stages (our training was directed to Geriatrics and Nephrology/Dialysis professionals); the empowerment and the increase in self-esteem that healthcare professionals gained, from learning about the logistical and structural organization of palliative care, to activate and implement PC; the need to share personal aspects of their professional life (this result emerges only in qualitative research); the appreciation of cooperation and the joining of multiple competences towards a synergistic approach and enhanced outcomes. Conclusion: It is necessary to further develop rigorous research on training evaluation, at the most complex orders of the Kirkpatrick and Moore models, to measure primary PC skills in health care professionals. This will develop the effectiveness of the integration of I- and II-level palliative care competencies in hospitals and improve outcomes of patients’ and families’ quality of life.
... Funding models may particularly influence the development and provision of palliative care in different national policy contexts [18]. However, a model that facilitates the expansion of generalist palliative care provision for all patients with advanced cancer, with specialized palliative care referral reserved for those with refractory symptoms and complex needs, may offer the best solution to ensuring timely access to palliative care services [12,19]. The strongest evidence for improved patient outcomes has come from integrating a specialized palliative care team alongside routine oncology care early in the disease course for patients with cancer [13,[20][21][22][23][24]. ...
Article
Full-text available
Opinion statement Evidence from randomized controlled trials and meta-analyses has shown that early integration of specialized palliative care improves symptoms and quality of life for patients with advanced cancer. There are various models of early integration, which may be classified based on setting of care and method of palliative care referral. Most successful randomized controlled trials of early palliative care have used a model of specialized teams providing in-person palliative care in free-standing or embedded outpatient clinics. During the COVID-19 pandemic, telehealth has become a prominent model for palliative care delivery. This model of care has been well received by patients and palliative care providers, although evidence to date is limited. Despite evidence from trials that routine early integration of palliative care into oncology care improves patient outcomes, referral to palliative care still occurs mostly according to the judgment of individual oncologists. This hinders equitable access to palliative care and to its known benefits for patients and their caregivers. Automated referral based on triggering criteria is being actively explored as an alternative. In particular, routine technology-assisted symptom screening, combined with targeted needs-based automatic referral to outpatient palliative care, may improve integration and ultimately increase quality of life.
... 11 However, workforce shortages make it impossible for palliative care specialists to care for more than a small percentage of these patients. [12][13][14] Innovative models are needed to improve the provision of primary palliative care, defined as basic symptom management and communication skills delivered by clinicians who are not palliative care specialists, within oncology practices. 15 The evidence base for primary palliative care interventions is limited, with many trials showing a high risk of bias (as assessed using the Cochrane Collaboration's risk-of-bias tool) 16, 17 and primarily focusing on inpatient or home settings. ...
Article
Importance Guidelines recommend early specialty palliative care for all patients with advanced cancer, but most patients lack access to such services. Objective To assess the effect of CONNECT (Care Management by Oncology Nurses to Address Supportive Care Needs), a primary palliative care intervention delivered by oncology nurses, on patient outcomes. Design, Setting, and Participants This cluster randomized clinical trial of the CONNECT intervention vs standard care was conducted from July 25, 2016, to October 6, 2020. Participants were adult patients with metastatic solid tumors who were undergoing oncological care and for whom an oncologist would agree with the statement “would not be surprised if the patient died in the next year.” The trial was conducted at 17 community oncology practices in western Pennsylvania. Data analyses adhered to the intention-to-treat principle. Interventions The CONNECT intervention included 3 monthly visits with an existing infusion room nurse who was trained to address symptoms, provide emotional support, engage in advance care planning, and coordinate care. Main Outcomes and Measures The primary outcome was quality of life. At baseline and 3 months, participants completed assessments of quality of life (Functional Assessment of Chronic Illness Therapy-Palliative care: score range, 0-184, with higher scores indicating better quality of life), symptom burden (Edmonton Symptom Assessment Scale: score range, 0-90, with higher scores indicating greater symptom burden), and mood symptoms (Hospital Anxiety and Depression Scale [HADS]: score range, 0-21, with higher scores indicating substantial anxiety and depression). Linear mixed-effects models were used to estimate adjusted mean differences in 3-month outcomes. Preplanned, intensity-adjusted analyses were conducted. Results A total of 672 patients were enrolled (mean [SD] age, 69.3 [10.2] years; 360 women [53.6%]). The mean (SD) number of CONNECT visits completed was 2.2 (1.0). At 3 months, no difference in mean (SD) quality-of-life score was found between the CONNECT and standard care groups (130.7 [28.2] vs 134.1 [28.1]; adjusted mean difference, 1.20; 95% CI, −2.75 to 5.15; P = .55). Similarly, there was no difference between groups in 3-month mean (SD) symptom burden (23.2 [16.6] vs 24.0 [16.1]; adjusted mean difference, −2.64; 95% CI, −5.85 to 0.58; P = .11) or mood symptoms (HADS depression subscale score: 5.1 [3.4] vs 4.8 [3.7], adjusted mean difference, −0.08 [95% CI, −0.71 to 0.57], P = .82; HADS anxiety subscale score: 5.7 [3.9] vs 5.4 [4.2], adjusted mean difference, −0.31 [95% CI, −0.96 to 0.33], P = .34). Intensity-adjusted analyses revealed a larger estimated treatment effect for patients who received a full dose (3 visits) of the CONNECT intervention. Conclusions and Relevance This cluster randomized clinical trial found that a primary palliative care intervention that was delivered by oncology nurses did not improve patient-reported outcomes at 3 months. Primary palliative care interventions with a higher dose intensity may be beneficial for most patients with advanced cancer who lack access to palliative care specialists. Trial Registration ClinicalTrials.gov Identifier: NCT02712229
... However, this model of care is currently impossible given the limited international palliative care infrastructure. [20,21] Although an interdisciplinary palliative team is desirable, the size of the hospital and the level of medical care available in a particular country may limit the range of health professionals in such teams. [22,23] Such problems make it difficult to meet the various needs of cancer patients when attempting to implement palliative care. ...
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Objectives The study aim was to determine the association between patient performance status (PS) and the contents of a palliative care team (PCT) intervention. Identifying intervention requirements for differing PS may help to provide appropriate palliative care in under-resourced facilities. Materials and Methods We collected data from medical records of inpatients ( n = 496) admitted to PCT services at a centre for palliative care at Kindai University Hospital, Japan, from April 2017 to March 2019. We analysed the content of PCT activities according to each PS using Pearson’s Chi-square test. Results The following PCT activities were provided in full regardless of PS: Gastrointestinal symptoms, depression, medical staff support, food and nutrition support and oral care. The following PCT responses were associated with PS: Pain, respiratory symptoms, fatigue, insomnia, anxiety, delirium, decision-making support, family support and rehabilitation. PS3 patients tended to receive those PCT interventions associated with PS, except for anxiety and fatigue. PS4 patients received PCT interventions for respiratory symptoms, delirium and family support. Patients with good PS (0–1) tended to receive PCT interventions for anxiety. Conclusion This study demonstrated that there were different needs for different PS. The results may allow for efficient interventions even in facilities with limited resources.
... Standardized referral based on these criteria may facilitate even earlier referral for these patients [10,18,20]. Earlier referral may be beneficial; however, many palliative care programs may not be able to handle to increased workload [29]. Individual institutions would need to decide which criteria subset should be adopted and/or modified-symptom, neurological, or time-based criteria [15]. ...
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Background An international panel achieved consensus on 9 need-based and 2 time-based major referral criteria to identify patients appropriate for outpatient palliative care referral. To better understand the operational characteristics of these criteria, we examined the proportion and timing of patients who met these referral criteria at our Supportive Care Clinic. Methods We retrieved data on consecutive patients with advanced cancer who were referred to our Supportive Care Clinic between January 1, 2016, and February 18, 2016. We examined the proportion of patients who met each major criteria and its timing. Results Among 200 patients (mean age 60, 53% female), the median overall survival from outpatient palliative care referral was 14 (95% confidence interval 9.2, 17.5) months. A majority (n = 170, 85%) of patients met at least 1 major criteria; specifically, 28%, 30%, 20%, and 8% met 1, 2, 3, and ≥ 4 criteria, respectively. The most commonly met need-based criteria were severe physical symptoms (n = 140, 70%), emotional symptoms (n = 36, 18%), decision-making needs (n = 26, 13%), and brain/leptomeningeal metastases (n = 25, 13%). For time-based criteria, 54 (27%) were referred within 3 months of diagnosis of advanced cancer and 63 (32%) after progression from ≥ 2 lines of palliative systemic therapy. The median duration from patient first meeting any criterion to palliative care referral was 2.4 (interquartile range 0.1, 8.6) months. Conclusions Patients were referred early to our palliative care clinic and a vast majority (85%) of them met at least one major criteria. Standardized referral based on these criteria may facilitate even earlier referral.
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The burden of nonpain symptoms such as anorexia, constipation, nausea, and vomiting contribute to patient suffering throughout the course of advanced illness. It is important to address symptom control throughout the disease trajectory, and especially at the end of life. Primary care clinicians must recognize these symptoms early, provide ongoing assessment, and keep abreast of evidence-based management strategies, including valid clinical protocols.
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Résumé Étayés par de nombreuses publications scientifiques qui en montrent les bénéfices cliniques, les soins palliatifs précoces sont devenus dès 2017 un gold standard en oncologie, recommandés par les grandes sociétés savantes d’oncologie pour les patients atteints de cancer avancé. Néanmoins, le recours à une équipe de soins palliatifs reste encore trop tardif en France et l’intervention des équipes de soins palliatifs en oncologie se limite encore trop souvent aux prises en charge du patient et de ses proches en fin de vie. Dans un premier temps, nous verrons quels sont les freins principaux: le manque d’effectifs des équipes de soins palliatifs et le fonctionnement complexe des lits identifiés de soins palliatifs; les difficultés de communication de l’oncologue avec le patient et ses proches pour l’introduction des soins palliatifs. Nous aborderons ensuite les perspectives de développement, en passant du concept de soins palliatifs précoces (systématiques dès la phase avancée) à celui de soins palliatifs intégrés (ciblés sur les besoins des patients). La standardisation du parcours de soins palliatifs intégrés nécessite la description précise des critères de recours, des modalités de screening, des missions cliniques spécifiques, ainsi que des modalités de collaboration avec les oncologues. Les équipes de soins palliatifs et d’oncologie, en travaillant ensemble, peuvent permettre une médecine holistique centrée sur les besoins des patients et de leurs proches, qui donne voix à leurs préférences dans le but d’améliorer leur qualité de vie.
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Unexpected, emergent surgical hospitalizations are common among patients with advanced cancer near end of life and pose an ethical challenge for acute care clinicians, including hospitalists, oncologists, and proceduralists. Referring to the principles of autonomy, beneficence, and nonmaleficence can guide clinicians to provide goal‐concordant care during an acute hospitalization that maximizes patient outcomes without prolonging suffering during the dying process.
Article
Purpose:: The proportion of patients with advanced cancer who receive outpatient specialty palliative care (OSPC) is as low as 2.0%. Improved understanding of the system-level factors influencing use of OSPC could inform adaptations to the delivery of palliative care to maximize access. We examined associations between OSPC use among patients with advanced solid tumors and oncology-OSPC clinic colocation and patient travel time to an OSPC clinic. Patients and methods:: We conducted a retrospective cohort study of patients with advanced solid tumors receiving oncologic treatment between January 1 and December 31, 2016, within a comprehensive cancer center network with well-established, oncology-specific OSPC clinics. Multivariable logistic regression analysis was used to evaluate the associations of clinic colocation and geographic access with OSPC use. Results:: Of 9,485 patients with advanced solid tumors, 478 (5.0%) received OSPC services in 2016. After controlling for age, sex, marital status, cancer type, insurance, treatment intent, and illness severity, patients whose oncologist practices were colocated with OSPC clinics were more likely to use OSPC (odds ratio [OR], 19.2; 95% CI, 14.1 to 26.2). Compared with patients who lived > 90 minutes from an OSPC clinic, patients with travel times of < 30 minutes (OR, 3.2; 95% CI, 2.2 to 4.6) and 31 to 60 minutes (OR, 2.4; 95% CI, 1.6 to 3.6) were also more likely to use OSPC. Conclusion:: Among patients with advanced solid tumors, colocation of oncology and OSPC clinics and shorter patient travel time were associated with greater odds of using OSPC. Future efforts to increase OSPC use in this population should consider clinic colocation and travel burden.
Article
Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.
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Background Compared to non-Hispanic Whites, Hispanic women are more likely to report pain, depression, and other mental health concerns. However, little is known about Hispanic women’s use of supportive medications, and whether use differs depending on nativity (US- vs. foreign-born). This study’s objectives were to examine patterns of supportive medication use and investigate potential differences by ethnicity/nativity among women with breast cancer. Methods We used the Surveillance, Epidemiology, and End Results data linked with Medicare claims to identify women diagnosed with incident breast cancer between July 1, 2007, and December 31, 2011. Supportive medication use (opioid pain and non-opioid psychotropic medications) in the 90 days after diagnosis was the primary outcome. We categorized ethnicity/nativity as US-Born non-Hispanic, US-born Hispanic, foreign-born non-Hispanic, and foreign-born Hispanic. Modified Poisson models examined associations between ethnicity/nativity and medication use, adjusting for tumor, treatment, and demographic characteristics. Results We included 23,091 women, of whom 88% were US-born non-Hispanics, 4% US-born Hispanics, 6% foreign-born non-Hispanics, and 2% foreign-born Hispanics. Supportive medication use varied by ethnicity/nativity. Compared to US-born non-Hispanics, foreign-born Hispanics and non-Hispanics were 5% (95% CI 0.92–0.98) and 10% (95% CI 0.85–0.96) less likely to receive supportive medications, respectively. US-born Hispanics were 5% (95% CI 1.02–1.09) more likely to receive supportive medications. Observed differences persisted when analyses were limited to stage I–III breast cancer cases. Conclusions This work highlights potential disparities in the pharmacologic treatment of psychosocial needs of foreign-born breast cancer patients. Future studies should explore if differences observed here are reflective of health disparities or differential patient preferences.
Article
Background: Palliative care (PC) education and research are essential to developing a skilled workforce and evidence base to support the delivery of quality cancer care. The current state of PC education and research at US cancer centers is unclear. In this national survey, the education and research programs of the National Cancer Institute (NCI)-designated and nondesignated cancer centers and the changes between 2009 and 2018 are compared. Methods: Between April and August 2018, PC program leaders at all NCI-designated cancer centers and a random sample of nondesignated centers were sent a survey to examine the structure, processes, and outcomes of their programs on the basis of questions from a 2009 national survey. This preplanned analysis focused on education and research. Results: There were 52 of 61 (85%) NCI-designated and 27 of 38 (71%) nondesignated cancer centers that responded. NCI-designated centers were more likely than nondesignated centers to have a PC fellowship program (87% vs 30%; P < .001), training for advanced practice providers (71% vs 44%; P = .03), PC research program (58% vs 15%; P < .001), peer-reviewed funding (43% vs 11%; P = .005), and philanthropic grants (41% vs 7%; P = .002). There were few significant improvements in PC education or research between 2009 and 2018 for both groups, notable exceptions include an increase in PC fellowships (38% vs 87%; P < .001) and mandatory PC rotations for medical oncology fellows (29% vs 55%; P = .02) at NCI-designated cancer centers. Conclusions: PC education and research are more developed at NCI-designated cancer centers. Despite some progress over the past decade, it is relatively slow and suboptimal.
Article
To the Editor In their Viewpoint,¹ Schenker and Arnold reflect about the currently published American Society of Clinical Oncology (ASCO) guideline that recommends that all patients with advanced cancer should receive palliative care. In doing this, they plead for a public health approach (instead of palliative care by palliative care specialists only) of providing palliative care as a core component of the health care system. We also believe that such an approach is the right way to go. Yet, we also believe that this Viewpoint neglects some important aspects that need to be explored beforehand, for example, whether and when patients in fact receive inadequate palliative care.
Article
45 Background: Cancer patients frequently experience short lengths of service in home hospice care. Methods: The Oncology Clinical Guidance Council, composed of medical, surgical, gynecological and radiation oncologists sets standards of care for the OhioHealth system serving central Ohio. The Council was polled for consensus on how long a cancer patient should be enrolled in hospice care. Then, median length of stay of patients referred by 18 medical oncologists from their offices to OhioHealth hospice for calendar year 2014 were obtained. A letter from the Chairs of the Oncology Clinical Guidancee Council was sent to each medical oncologist noting the council's opinion about optimal length of stay, the length of stay reported by the National Hospice and Palliative Care Organization (NHPCO), and the median length of stay of all patients referred by OhioHealth oncologists. A chart graphing the median length of stay by oncologist, indicating the name of the oncologist to which the letter was directed, was mailed to each oncologist. One year later, for calendar year 2015, the measurement of median length of stay by oncologist was repeated. Results: 64% of the Oncology Clinical Guidance Council members polled think the median length-of-service for hospice care for cancer patients should be 90 days (3 months) and 20% think it should be 45 days (6 weeks). The NHPCO national median is 43 days. At baseline, the median length of stay for 176 cancer patients referred in calendar 2014 was 19.7 days. The median length of stay for 133 patients referred in the first 10 months of 2015 was 39.6 days. Conclusions: A simple quality improvement approach to improving hospice length of service by oncologists yielded a doubling to reach the national median in one year.
Article
Purpose To provide evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists to update the 2012 American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) on the integration of palliative care into standard oncology care for all patients diagnosed with cancer. Methods ASCO convened an Expert Panel of members of the ASCO Ad Hoc Palliative Care Expert Panel to develop an update. The 2012 PCO was based on a review of a randomized controlled trial (RCT) by the National Cancer Institute Physicians Data Query and additional trials. The panel conducted an updated systematic review seeking randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of RCTs in the 2012 PCO, published from March 2010 to January 2016. Results The guideline update reflects changes in evidence since the previous guideline. Nine RCTs, one quasiexperimental trial, and five secondary analyses from RCTs in the 2012 PCO on providing palliative care services to patients with cancer and/or their caregivers, including family caregivers, were found to inform the update. Recommendations Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.
Article
Purpose: There is growing interest to enhance symptom monitoring during routine cancer care using patient-reported outcomes, but evidence of impact on clinical outcomes is limited. Methods: We randomly assigned patients receiving routine outpatient chemotherapy for advanced solid tumors at Memorial Sloan Kettering Cancer Center to report 12 common symptoms via tablet computers or to receive usual care consisting of symptom monitoring at the discretion of clinicians. Those with home computers received weekly e-mail prompts to report between visits. Treating physicians received symptom printouts at visits, and nurses received e-mail alerts when participants reported severe or worsening symptoms. The primary outcome was change in health-related quality of life (HRQL) at 6 months compared with baseline, measured by the EuroQol EQ-5D Index. Secondary endpoints included emergency room (ER) visits, hospitalizations, and survival. Results: Among 766 patients allocated, HRQL improved among more participants in the intervention group than usual care (34% v 18%) and worsened among fewer (38% v 53%; P < .001). Overall, mean HRQL declined by less in the intervention group than usual care (1.4- v 7.1-point drop; P < .001). Patients receiving intervention were less frequently admitted to the ER (34% v 41%; P = .02) or hospitalized (45% v 49%; P = .08) and remained on chemotherapy longer (mean, 8.2 v 6.3 months; P = .002). Although 75% of the intervention group was alive at 1 year, 69% with usual care survived the year (P = .05), with differences also seen in quality-adjusted survival (mean of 8.7 v. 8.0 months; P = .004). Benefits were greater for participants lacking prior computer experience. Most patients receiving intervention (63%) reported severe symptoms during the study. Nurses frequently initiated clinical actions in response to e-mail alerts. Conclusion: Clinical benefits were associated with symptom self-reporting during cancer care.
Article
In the context of the establishment of a new medical specialty, rapid growth in hospices and palliative care programs, and many anecdotal reports about long delays in filling open positions for hospice and palliative medicine (HPM) physicians, the American Academy of Hospice and Palliative Medicine (AAHPM) appointed a Workforce Task Force in 2008 to assess whether a physician shortage existed and to develop an estimate of the optimal number of HPM physicians needed. Develop estimates of the current supply and current need for HPM physicians. Determine whether a shortage exists and estimate size of shortage in full-time equivalents (FTEs) and individual physicians needed. The Task Force projected national demand for physicians in hospice- and in hospital-based palliative care by modeling hypothetical national demand on the observed pattern of physician use at selected exemplar institutions. The model was based on assumptions that all hospices and hospitals would provide an appropriate medical staffing level, which may not currently be the case. Approximately 4400 physicians are currently HPM physicians, as defined by board certification or membership in the AAHPM. Most practice HPM part time, leading to an estimated physician workforce level from 1700 FTEs to 3300 FTEs. An estimated 4487 hospice and 10,810 palliative care physician FTEs are needed to staff the current number of hospice- and hospital-based palliative care programs at appropriate levels. The estimated gap between the current supply and the hypothetical demand to reach mature physician staffing levels is thus 2787 FTEs to 7510 FTEs, which is equivalent to 6000-18,000 individual physicians, depending on what proportion of time each physician devotes to HPM practice. An acute shortage of HPM physicians exists. The current capacity of fellowship programs is insufficient to fill the shortage. Changes in graduate medical education funding and structures are needed to foster the capacity to train sufficient numbers of HPM physicians.
Delivering more, earlier, and better goals-of-care conversations to seriously ill oncology patients
  • R Bernacki
  • Pj
  • D Lamas
  • M Hutchings
Bernacki R PJ, Lamas D, Hutchings M, et al. Delivering more, earlier, and better goals-of-care conversations to seriously ill oncology patients. J Clin Oncol. 2015;33(suppl 29S; abstr 39).