The inaugural Palliative Care in Oncology Symposium, held this past October, drew close to 700 attendees from medical, radiation, and surgical oncology, as well as from hospice, palliative care, and other symptom-management specialties.

As a way to continue the discussion from the meeting, ASCO Connection will be publishing attendee questions posed during the Symposium with responses from faculty.

The questions below were posed during General Session 3: Skills for Addressing the End of Life, and responses are from session Co-Chair, Timothy J. Moynihan, MD. Dr. Moynihan is the Inpatient Practice Chair for the Department of Medical Oncology, Director of the Brain Tumor Clinic, and the Hospice Medical Director at the Mayo Clinic, Rochester.

The Symposium was co-sponsored by the American Society of Clinical Oncology (ASCO), the American Academy of Hospice and Palliative Medicine (AAHPM), the American Society for Radiation Oncology (ASTRO), and the Multinational Association of Supportive Care in Cancer (MASCC). Next year’s Symposium will be held October 9-10, 2015, in Boston.

Q: There were a few examples in this session of the physician as friend or companion to the patient. There are statistics that suggest two-thirds of palliative care visits are at the end of life and are for companionship. Although I support person-centered medicine, I challenge the panel to reflect on a public health approach, in which the broader community supports the "social" aspects of palliative care, and the oncologist and other specialists provide high-quality clinical palliative care. Provision of palliative care is everyone's business, and we all play a role.

Dr. Moynihan: I would agree with the sentiments by the questioner—palliative care is everyone’s business. Unfortunately, much of this companionship and social support currently falls to an ill-prepared family and social network. On top of that, many physicians are ill prepared to help (even if they have a strong desire to help). This is where expansion of palliative care training to include all practitioners who treat patients will, hopefully, help—keeping the specialty-trained palliative care practitioners for the especially difficult cases.

Q: Could someone comment on the disparity between how well successful medical oncologists feel that they are at providing palliative care versus the reality of the quality of care that they are providing?

Dr. Moynihan: Elizabeth Bradley’s¹ study from 2002 showed that knowledge and attitude of the physician did correlate with probability of early hospice or palliative care referral; however, that does not answer the question of how well do oncologists actually deliver the care. A study of European medical oncologists determined that only 35% collaborated often with a palliative care specialist.²  An Australian study surveyed 699 medical oncologists, clinical hematologists, respiratory physicians, and colorectal surgeons, 88% of whom felt that they should coordinate end-of-life care for their patients. Only 42% of those felt adequately trained for this.³ However, 48% of those surveyed referred more than 60% of their patients to palliative care services.

Q: As a palliative care specialist working in an oncology center, I [often find that oncologists are burned out]. They seem to be tired of taking their chances in the “chemotherapy lottery” and of navigating a world of unrealistic expectations. What do you believe the role of the palliative care team should be regarding oncologist burnout? Can we care for our oncologists better and, if so, how?

Dr. Moynihan: Hopefully, the palliative care team can alleviate some of the burden for their oncology colleagues through attention to the early signs and symptoms of burnout such as depersonalization, lack of interest in the job, fatigue, depression, anxiety, irritability, and inability to concentrate. Modes of dealing with burnout include resiliency training, exercise, and gaining increased control over schedule and tasks. None of these methods have been rigorously tested in prospective trials.  

Q: Does the subspecialty of palliative care possibly represent a threat to the actual provision of palliative care because other specialists might decide that end-of-life care in particular is not their problem?

Dr. Moynihan: I think this is one fear of palliative care providers, that every ache and pain might be viewed by the oncologist as “not my problem” and be given over to the palliative care team. Hopefully, the integration of palliative-care training into the education of oncologists will help them to see this is a normal and expected part of patient care, encouraging them to incorporate palliative care when needed.

References:

1.                   Bradley EH, Cramer LD, Bogardus ST Jr, et al. Physicians' ratings of their knowledge, attitudes, and end-of-life-care practices. Acad Med. 2002;77(4):305-311.

2.                   Cherny NI, Catane R, European Society of Medical Oncology Taskforce on Palliative and Supportive Care. Attitudes of medical oncologists toward palliative care for patients with advanced and incurable cancer: Report on a survey by the European Society of Medical Oncology Taskforce on Palliative and Supportive Care. Cancer 2003;98(11):2502-2510.

3.                   Johnson CE, Girgis A, Paul CL, et al. Cancer specialists' palliative care referral practices and perceptions: Results of a national survey. Palliat Med. 2008;22:51-57.

NOTE: For more Q&As from the Palliative Care Symposium, please read:
--Part 2 "Integrating Palliative Care into a Health System: A Continuing Conversation (Part 2)," featuring responses by Charles F. von Gunten, MD, PhD, Vice President of Medical Affairs, Hospice, and Palliative Care at OhioHealth Kobacker House and Editor-in-Chief of the Journal of Palliative Medicine.
 

—Part 3 of the Continuing Conversation series: “Advance Directives and Advance Care Planning: A Continuing Conversation (Part 3)” featuring responses by Joanna Paladino, MD, who presented on this topic at the Symposium and who is a research fellow for the Serious Illness Care Program at Ariadne Labs, which is a joint Innovation Center of the Harvard School of Public Health and Brigham and Women’s Hospital. Additional authors, all also from the Serious Illness Care Program at Ariadne Labs, included: Rachelle Bernacki, MD, MS, associate director; Francine Maloney, MPH, project manager; and Susan Block, MD, director.

For more information on the 2014 Palliative Care Symposium, please see "Video Highlights from the Inaugural Palliative Care in Oncology Symposium."