The Transition to Palliative Care Does the patient have one of the following: Metastatic cancer progressing after first line treatment Performance status ECOG 2 and deteriorating Acute oncology or unplanned admission Severe or overwhelming symptoms Anorexia, hypercalcemia, or any effusion Moderate or severe psychological or existential distress Complex social issues
1. Use the Integrated Patient Outcome Scale (IPOS) to assess level of symptom and other palliative care concerns 2. Discuss changing focus of care towards palliation and address concerns flagged in IPOS
No or low concerns identified
Review again in eight to twelve weeks Offer Oncology CNS as point of contact for changing concerns
Moderate concerns identified
Appointment with oncology CNS* to develop personalised care plan to address these and future care needs
High level of concerns identified
Develop personalised care plan (with oncology CNS if appropriate) including referral to specialist palliative care
*or equivalent professional You can contact your specialist palliative care team at: Insert details of contacts/referral here
Don’t delay palliative care because disease-directed treatment is continuing
Background “Principles of palliative care have long featured in the training of oncologists. Core skills include breaking significant news, pain & symptom management… and particularly facilitating transition from predominantly oncological care to palliative care.” 12 Many oncology professionals fear distressing their patients, but most patients want honest and open discussions, but are often reluctant to raise issues themselves, and wait for them to be initiated by a professional, and the small proportion who do not want to talk will usually clearly indicate this. Why identify palliative care needs? Patients with advanced cancer have reported high levels of unmet needs related to difficult physical symptoms, wanting more information, needing emotional support, and having complex practical, family, social and spiritual needs4.Substantial evidence demonstrates that if Oncologists refer to Palliative Care – when combined with standard cancer care or for palliative care on its own – this leads to better patient and caregiver outcomes15. For these patients early consideration of Palliative Care needs, can give them improved quality of life, extra quality of care, and equal or better survival. Evidence from randomised controlled trials and other sources has shown that palliative care improves quality of life for those with advanced cancer, with fewer symptoms and less anxiety and less depression1,2,5,7,17. Palliative care alongside usual oncology care does not worsen survival1,2,5,7. Cancer care costs are rising exponentially9 but palliative care programmes can save money for hospitals and health systems2,5,16. Every study to date shows that adding palliative care delivers significant savings (or at worst is costneutral ) in addition to delivering better care2,5,10,11,16. When to identify palliative care needs? Earlier than we think: for individual patients, cancer can have an unexpectedly rapid progressive phase in the final stages; studies of oncologists’ (and others) predictions of prognoses found that we consistently over-estimate in cancer6. There is good evidence that some objective prognostic indicators point to a prognosis of less than six months for advanced cancer patients when ECOG Performance Status is 2 and declining, there is anorexia, hypercalcemia, or any effusion, or metastatic cancer has progressed on one line of treatment14. How to identify palliative care needs? Palliative care needs, including symptoms, can be quickly and easily assessed using IPOS (the integrated Patient care Outcome Scale). This is a valid and reliable, yet brief, measure which can be used to assess a patient’s symptom and other palliative care issues. It can be completed by a patient, with family help or alone, in an outpatient or inpatient setting (such as while waiting for a clinic appointment). Severe or overwhelming symptoms or other concerns, should result in referral to specialist palliative care. A measure is useful since it is not easy to discuss: 60% of us prefer not to have hard conversations about deteriorating health and prognosis until “there are no more treatment options left”8. Helpful questions to ask patients What is your current understanding of your illness? What is important to you? What is your understanding of what is likely to happen to you? What do you expect from treatment? What do you think the future holds for you? References 1. Bakitas M, Lyons K, Hegel MT, et al.JAMA : the journal of the American Medical Association 2009; 302(7): 741-9. 2. Brumley R, Enguidanos S, Jamison P, et al. Journal of the American Gerontology Society 2007; 55(7): 993-1000. 3. Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Journal of Pain and Symptom Management 2007; 33(3): 238-46. 4. Carey M, Lambert S, Smits R, Paul C, Sanson-Fisher R, Clinton-McHarg, T. Supportive Care in Cancer2012; 20: 207-219 5. Gade G, Venohr I, Conner D, et al. Journal of Palliative Medicine. March 2008; 11(2): 180-190. doi:10.1089/jpm.2007.0055. 6. Glare, P, Virik, K, Jones, M, Hudson, M, Eychmuller, S,Simes, J, et al. BMJ 2003; 327: 195 10.1136/bmj.327.7408.195 7. Khatcheressian J, Cassel JB, Lyckholm L, Coyne P, Hagenmueller A, Smith TJ. Oncology (Williston Park), 2005 Sep;19(10):1365-76; discussion 1377-8, 1381-2, 1384. PMID: 16285228 [PubMed - indexed for MEDLINE] 8. Mack JW, Cronin A, Keating N et al. Annals of internal medicine 2012; 156(3): 204-10 9. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Journal of the National Cancer Institute 2011; 103(2): 117-28. 10. Morrison RS, Penrod JD, Cassel JB, et al. Archives of internal medicine 2008; 168(16): 1783-90. 11. Morrison RS, Dietrich J, Ladwig S, et al. Health affairs (Project Hope) 2011; 30(3): 454-63. 12. Royal College of Physicians. Cancer Patients in Crisis: redsponding to urgent needs. Report of a working party. London: RCP, 2012 13. Saito A, Landrum MB, Neville B et al. Journal of Palliative Medicine 2011, 14(8): 929-39. 14. Salpeter SR, Malter DS, Luo EJ, Lin AY, Stuart B. Journal of palliative medicine 2012; 15(2): 175-85. 15. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology The Integration of Palliative Care into Standard Oncology Care. Journal of Clinical Oncology 2012; 30: 880-887 16. Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA. Journal of palliative medicine 2003; 6(5): 699-705. 17. Temel JS, Greer JA, Muzikansky A, et al. NEJM 2010; 363(8): 733-42.
