Jul 27, 2015
By Collin T. Zimmerman, MD
As oncology fellows we are called to address the symptoms, emotional charge, and spiritual and family conflicts that can come with a cancer diagnosis. Drawing upon the experience and support of palliative care consultants can be a great way to bring their expertise to bear on a difficult clinical situation. The skills in communication, symptom management, and self-care displayed by the palliative care team facilitate connecting with and effectively caring for patients in challenging situations. Having completed a fellowship in palliative care at San Diego Hospice and the Institute for Palliative Medicine in 2013 and now approaching the final year of my hematology-oncology training at Mayo Clinic, it is clear to me that many of these skills are fundamental to both fields and that palliative medicine principles are a crucial part of our oncology training.
Effective communication is the cornerstone of palliative care. Palliative care providers have to work to help patients reach an understanding of their disease and its implications. Delivering bad news is a common component, as are establishing goals and helping patients and families make treatment decisions aimed at accomplishing these goals. Palliative care practitioners have a great deal of experience in bringing family and patients together and creating consensus for treatment decisions under difficult circumstances. Conflict and volatile emotions during these meetings are common. The importance of communication training is well recognized as a critical part of oncology training.1 We face many similar scenarios in the clinic and hospital services as our palliative care colleagues. Rotating with palliative care teams in our training is an opportunity to supplement and enhance our communications skills.
Management of complex symptoms is another area where oncology and palliative care overlap and can inform each other. Palliative care practitioners recognize that suffering related to a cancer diagnosis can manifest physically, emotionally, and/or spiritually. Physical manifestations can include nausea, pain, and dyspnea. Emotional suffering can include depression or anger. Spiritual suffering can include grieving, losing one’s role or sense of self, questioning God, or seeing the events as a punishment for past deeds. Physical symptoms are frequently influenced or exacerbated by unaddressed suffering related to familial conflict, grief, and spiritual concerns. Dame Cicely Saunders, the founder of modern hospice, termed this “total pain.”2 Palliative care teams use a multidisciplinary approach to address all types of suffering. Expert use of medications to alleviate physical symptoms is only one important element in total patient care. Addressing the less tangible dimensions of suffering can be challenging, requiring the use of chaplain support and recognizing spiritual and emotional concerns as important. Simply identifying sources of spiritual suffering can be therapeutic and can often help in addressing refractory physical symptoms. Training in pharmacologic management of symptoms and an ability to recognize and address spiritual suffering can be equally helpful.
The management of actively dying patients is another area of common ground for palliative care and oncology. Our palliative care colleagues treat actively dying patients in very diverse settings, from patient homes with hospice to the intensive care unit. Instruction and training in symptom management for dying patients can be very beneficial and add to the practices we develop during our oncology training. Dying patients are frequently cared for on our oncology ward, and it is critically important to be able to manage their symptoms well and support the family through this difficult process.
In oncology, despite our amazing connection with our patients and often intense sense of grief and loss that can accompany this relationship, self-care for providers is often an unwritten part of the curriculum. Palliative care and hospice practitioners deal with death and loss in their practices on a daily basis, and coping with those emotional challenges is a major focus of the culture of these disciplines. Self-care is an ingrained part of hospice work as well, and group reflection is a common part of the regular hospice interdisciplinary group meeting. Finding ways to process and reflect on challenging patient encounters and losing our patients is critical to our emotional health and avoiding burnout. Hospice and palliative care practitioners often have battle-tested methods of coping with the emotional rigor of this work, and this is something we can learn and emulate.
There are many ways to get more exposure to palliative care during oncology training. ASCO is undertaking research in ways to better deliver palliative care teaching to oncology fellows, in partnership with the American Association of Hospice and Palliative Medicine (AAHPM). ASCO has been a vocal advocate for integration of palliative care training in oncology trainee curricula with a focus on pain and symptom management, education in patient and family communication, and psychosocial support.3 There are a number of resources available through ASCO University®, including ASCO-SEP® (which includes chapters and selfassessment opportunities on symptom management and palliative and end-oflife care), the Education in Palliative and End-of-Life Care for Oncology course (EPEC-O), and courses on symptom management, communication, and end-of-life decision-making. ASCO’s cosponsored Palliative Care in Oncology Symposium will take place in Boston, MA, on October 9-10, 2015. At Mayo Clinic and at many other programs, fellows rotate at local hospices and with the palliative care consultation services.
Core palliative care concepts of treating pain and physical symptoms, recognizing spiritual suffering, and coping with emotional challenges are critical for all oncology trainees to allow them to provide primary palliative care. There is an important role for palliative care specialists to work in consultation with challenging cases. In my experience, palliative care training has added nuance to fundamental communication and symptom management skills, has helped me connect with my patients and their families, and has helped me manage the emotional rigors of training.