Early ambulatory palliative care visits focus on psychosocial elements such as building rapport and coping, as well as managing symptoms and enhancing illness understanding
- Correspondence to
: Dr Betty Ferrell
Department of Nursing Research and Education, City of Hope, 1500 E. Duarte Road, Duarte, CA 91010, USA;
Implications for practice and research
In 2010, a key trial testing a palliative care intervention for patients with non-small-cell lung cancer was published.1 This study has had significant impact, but many professionals have asked for more details about palliative care interventions.
Findings from the present study will help define what palliative care specifically provides.
Professional organisations in the fields of oncology, such as the American Society of Clinical Oncology2 and palliative care, including the American Academy of Hospice and Palliative Medicine, have articulated the need for palliative care to be integrated into disease-focused care. There has been a wide international interest in this area as well. Achieving this aim will require a greater understanding of the components of palliative care interventions in order to develop generalisable models of care. The National Consensus Project for Quality Palliative Care (NCPQPC)3 identifies eight domains of palliative care: (1) structure and processes of care, (2) physical aspects of care, (3) psychological and psychiatric aspects of care, (4) social aspects of care, (5) spiritual, religious and existential aspects of care, (6) cultural aspects of care, (7) care of the patient at the end of life and (8) ethical and legal aspects of care.
Yoong and colleagues sought to describe the elements of palliative care delivered through a palliative care intervention. Twenty patients were selected who had participated in the previous palliative care trial and were stratified by the length of survival. Audits of the electronic health record, including palliative care and oncologist chart notes, were analysed. Content analysis was used to identify components of the oncological and palliative care visits. The analysis of the actual care delivered was intended to describe in further detail the care provided and also to distinguish between the disciplines of palliative care and oncology. This analysis was intended to determine if palliative care offered unique contributions to the care of oncology patients. The study was well designed to assess patients with both short-term and long-term survival in order to determine the contribution of palliative care across the trajectory.
The results of the content analysis recognised that symptom management and coping were the most common elements of palliative care visits. Earlier visits addressed building support with patients and families and illness understanding. Later visits focused on resuscitation preferences and hospice care. The oncology and palliative care visits both addressed the symptoms and illness status, but palliative care visits emphasised the emotional needs.
This study contributes to the growing body of evidence that palliative care should be integrated into routine oncology care. The patient outcomes of palliative care include improved quality of life, symptoms, communication and decision-making and earlier access to supportive care services and transition to hospice. This analysis illuminates the aspects of simultaneous care that can lead to these benefits. This study is also valuable in its focus on the ambulatory care setting where most oncology care now occurs rather than on inpatient palliative care consultation. This understanding of the nature of palliative care also adds to the growing awareness of cost savings from palliative care. Patients who have had supportive communication and decision-making avoid futile chemotherapy in the last weeks of life and other costly treatments incongruent with the goal of care before imminent death.2
The study findings contribute to an awareness of the need for earlier referral to palliative care. The findings demonstrated that the palliative care provider needs time to establish a trusting relationship before addressing the difficult topics such as ‘do not resuscitate’ decisions and referral to hospice. The authors conclude that the palliative care consultation offers unique contributions to patient care across the care trajectory and that the use of palliative care allows oncologists to focus on cancer treatment. These findings are very important for the future of oncology care. Oncology workforce shortages are anticipated and the population is aging, resulting in substantial increases expected in cancer cases. The findings indicate that both oncologists and palliative care professionals contribute to the domains described by the NCPQPC including physical, psychosocial and spiritual needs.3 A strength of the interdisciplinary approach in care is provided by doctors, nurses, social workers and chaplains with palliative care expertise to meet the complex needs of patients at the end of life.