Even though palliative care has been an important aspect of medical care in the United States for more than 25 years, it has yet to gain full public acceptance. Attempts to offer advanced care planning that allows patients to focus on care consistent with their values and preferences have been met with resistance. On January 1, 2011, Medicare proposed clinician reimbursement for advanced care planning. Within several weeks, however, this recommendation was reversed because some politicians worried the public would equate advanced care planning with healthcare rationing. Our recent publication in The New England Journal of Medicine directly addresses the impact of timely palliative care on quality of life and end-of-life care in patients with metastatic non–small cell lung cancer.1 The article promoted conversation within the healthcare community about the benefits of palliative care as part of comprehensive oncology care.
Background Studies demonstrate that patients with cancer are often offered palliative care too late in the course of their illness. One reason for delayed referrals is the lack of clinician understanding and experience with palliative care. Even Atul Gawande, MD, MPH, noted writer with The New Yorker, publicly acknowledged his confusion regarding the role of palliative care in patients who are not receiving hospice care. Until recently, he thought of the difference between standard medical care and palliative care as “the difference between treating and doing nothing.”2
Our randomized controlled trial demonstrated the benefit of offering palliative care closer to diagnosis, confirming that standard medical care and palliative care are not mutually exclusive. As such, its publication spawned coverage in national print media, including The New York Times, The Boston Globe, and USA Today; and received nationwide television coverage on NBC Nightly News and National Public Radio. Endorsed by all major hospice and palliative care organizations— the Hospice and Palliative Nurses Association, the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, and the National Hospice and Palliative Care Organization—the study cultivated discussion from other prominent healthcare institutions, with statements issued in response to the findings from the John Hartford Center, the National Cancer Institute, and the American Society of Clinical Oncology (ASCO).
A Randomized Controlled Trial of Early Palliative Care Our study investigated the impact of early palliative care on quality of life and survival in patients with metastatic cancer. We randomized 151 patients with newly diagnosed metastatic non– small cell lung cancer to receive early palliative care integrated with standard oncology care (n = 77) or standard oncology care (n = 74). Patients assigned to early palliative care received at least 1 visit per month from the palliative care team in the ambulatory care setting throughout the course of their disease. Patients were also assured of 24/7 coverage by the palliative care team in response to any change in cancer status, worsening of symptoms, or difficulties in coping. The mean number of visits at 12 weeks postdiagnosis for patients receiving early palliative care was 4 (range, 0-8).
The palliative care team at Massachusetts General Hospital has provided inpatient care for 15 years and outpatient care for 10 years. During this study, the outpatient team consisted primarily of 6 palliative care physicians and 1 palliative care advanced practice nurse. Patient appointments were scheduled concomitantly with appointments with the oncology team or with chemotherapy or radiation treatment. To assure continuity of care, after randomization to a specific palliative care clinician, each patient received treatment primarily from that provider.
Standard oncology care was not dictated by the study protocol and incorporated any treatment recommended by the oncologist, including chemo therapy, radiation, and surgery. Patients assigned to the standard care group were not prohibited from receiving palliative care. The treatment team, the patient, or the patient’s family could subsequently request a consult for palliative care. Only 10/74 (14%) patients receiving standard care had a palliative care visit in the first 12 weeks after diagnosis.
The study confirmed the hypothesis held within the palliative care community: Early palliative care provides significant benefits, even while patients are receiving cancer-directed therapies.3 Patients assigned to early palliative care had better quality of life compared with those receiving standard oncology care, as measured by the Trial Outcome Index (59.0 ± 11.6 vs 53.0 ± 11.5, respectively; P = .009). They also had lower rates of depression than patients in the standard care group, as measured by the Hospital Anxiety and Depression Scale (16% vs 38%, respectively; P = .01). Patients receiving early palliative care were less likely than patients in the standard care group to receive aggressive end-of-life care, defined by ASCO as chemotherapy within 14 days of death, no hospice care, or admission to hospice ≤3 days prior to death (33% vs 54%, respectively; P = .05). We hypothesize that early intervention with palliative care promoted candid discussions regarding end-of-life care options and prognosis, thereby influencing decisions favoring better quality of life over aggressive, likely ineffective therapies.
Our study also found that patients receiving early palliative care lived longer than patients receiving standard oncology care. Despite receiving less aggressive end-of-life care, patients assigned to early palliative care survived 30% longer than those assigned to standard oncology care (median, 11.6 vs 8.9 months, respectively; P = .02). This finding contradicts the common assumption that less aggressive end-of-life care decreases longevity.
Discussion Using a randomized trial design, our study found that early palliative care improves quality of life and reduces depression. There are several possible explanations for these effects. First, aggressive end-of-life care may produce sufficiently high levels of psychological distress when treatment produces more harm than good. Second, palliative care offers a high degree of psychosocial support and thus may directly reduce psychologic distress at the end of life.
Although these results are exciting and strongly support the notion that palliative care has beneficial effects, our study had a number of limitations. The study enrolled only patients with metastatic non–small cell lung cancer, and the findings may not be generalizable to other cancer populations. In addition, the study was conducted at a single tertiary care hospital with a mature, well-established, palliative care team that already had a collaborative relationship with the oncology division. Further studies should be conducted in other academic settings and use palliative care teams in varying stages of development to confirm our findings. Our study population was fairly homogeneous, with a predominance of white patients, and this limits the ability to generalize these findings to patient populations with more diverse cultural backgrounds.3
Nursing Implications Oncology nurses in all settings are frequently present at the bedside, affording them abundant opportunities to initiate conversations that allow patients to reflect on their physical condition; their views on good quality of life; and their values, preferences, and beliefs about life-prolonging therapies. Many oncology nurses are present and provide oncology and palliative care at the time of diagnosis, during treatment, at recurrence, and at the news of disease progression. Nurses offer support and comfort at these transitions, particularly after difficult conversations with physicians and oncology nurse practitioners. 4 Careful timing and the skillful delivery of palliative care are essential to nurture and strengthen the nurse– patient relationship.
Oncology nurses can also promote early initiation of palliative care and its positive role to patients and the treating team. This can be done in conjunction with discussions on other aspects of comprehensive cancer care. For example, nurses might offer patients and their family access to a team that focuses on pain and symptom management and psychosocial support to improve quality of life. They can dispel concerns and fears that palliative care shortens life. Nurses are in a position to encourage acceptance and trust of palliative care and can introduce team members directly to patients and their families. They may also be able to recognize patients struggling with cancer treatment who need palliative care to help them complete therapy. For patients who are told no more treatment options are available, oncology nurses should discuss the benefits of and options for palliative care.
To help nurses provide comprehensive care for patients, they must strive to understand the importance of integrating palliative care into oncology care and pursue education in palliative care. The Oncology Nursing Society (ONS) partnered with the End-of-Life Nursing Education Consortium to create a curriculum for oncology nurses, which is available at many ONS Annual Congresses. This curriculum offers nurses structured education through 9 modules: Overview of Palliative Nursing, Achieving Quality Care, Communication, Pain Management, Symp tom Management, Loss and Grief, Culture, Final Hours, and Ethics.5 In addition, oncology nurses should familiarize themselves with the National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines. These guidelines cover 8 domains: Structure and Processes of Care; Physical Aspects of Care; Psychological and Psychiatric Aspects of Care; Social Aspects of Care; Spiritual, Religious and Existential Aspects of Care, Cultural Aspects of Care; Care of the Imminently Dying Patient; and Ethical and Legal Aspects of Care.6
Conclusion Our study demonstrates the benefits of early palliative care: better quality of life, lower rates of depression, less aggressive end-of-life care, and in creased survival, even in the absence of aggressive end-oflife treatment. With this new evidence, oncology nurses should feel more confident about promoting palliative care to their patients.
References
To sign up for our newsletter or print publications, please enter your contact information below.
