Issues in Promoting Early Palliative Care

In this first segment of a new one-on-one interview series, a part of the Oncology Stakeholders Summit, Spring 2015 series, Bruce Feinberg, DO, and Brian Kiss, MD, address several general issues related to palliative care services, including how, in the United States, their use seems to be ill-defined and poorly utilized.

Dr Feinberg, vice president and chief medical officer for Cardinal Health Specialty Solutions, explains that a few aspects of the problem are that palliative care services are not well defined, practice guidelines from major providers are vague, and it is not clear who on the care team should lead oncology palliative care efforts. The National Comprehensive Cancer Network (NCCN) guidelines on palliative care are nonspecific, agrees Dr Kiss, vice president, healthcare transformation, Blue Cross Blue Shield of Florida.

Palliative care utilization remains a problem: only 50% of cancer patients are getting into hospice, says Dr Feinberg, and for those patients, the average length of stay is about a week—because they aren’t being admitted to hospice early enough. In addition, “More are ending up in ICU than ever before in the last month of life.”

Dr Kiss believes that part of the problem is that doctors tend to discuss palliative care only after active treatment options for advanced cancer have been exhausted. Instead, he states, palliative care discussions should happen much earlier in treatment, “even as part of the care in the primary care setting.”

There also seems to be a turf battle over who should be involved in palliative care services and when. Palliative care physicians think they should play a role in symptom management during the entire continuum of care, says Dr Feinberg. On the other hand, oncologists think symptom management is their job. Patients, on the other hand, are reluctant to discuss palliative care early on. A pilot project has elicited physician opinion as to when might be the right time to start this conversation with the patient. The response has been “when they order the last line of treatment that has survival benefit evidence,” Dr Feinberg commented. This will differ by cancer type, eg, beginning third-line treatment for breast cancer as opposed to second-line therapy for lung cancer.

Dr Kiss emphasizes that rather than define a transition between active treatment and palliative treatment, it may be more important to begin palliation of symptoms even when cure may be possible.