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Integrating Palliative Care Into Outpatient Oncology: A Case Study

Karen Mulvihill, DNP, APRN, FNP-BC, ACHPN
This article examines the integration of palliative care in a community cancer center-an example of how one program integrated palliative care.
Education has been identified as a barrier to quality palliative care services in oncology. The 2014 Institute of Medicine (IOM) report, Dying in America, recommends that “Educational institutions, professional societies, accrediting organizations, certifying bodies, healthcare delivery organizations, and medical centers take measures to both increase the number of palliative care specialists and expand the knowledge base for all clinicians.”11 Physicians and nurses often feel ill-prepared to discuss palliative or EOL care with their patients and families. A study among 675 nurses and physicians identified need for more basic information on palliative care, improved training on communication skills, and knowledge of how to take better care of the patient’s caregivers.12 When Horlait et al examined what oncologists identified as barriers in discussing palliative care with their patients, they found that these discussions were perceived as a “complex and emotional task,” which in turn led to palliative care referrals being made late in the course of the illness.13

The benefits of palliative care can be seen at any age level. Mahmood et al found that not only is palliative care feasible for children with highrisk cancer, but was also acceptable to the children, families, and pediatric oncologists.14 Caring for older adults with cancer can be challenging because they often suffer multiple co-morbidities and decreasing functional status, which need to be takeninto consideration when discussing treatment options. Palliative care should be provided from the moment of diagnosis to ensure adequate symptom management and to ensure that treatments are aligned with the patient’s preferences and values.15 Palliative care can prove beneficial to a host of individuals, including cancer survivors,16 hematopoietic transplant patients,17 patients with hematological malignancies,18 adolescents and young adults,19 as well as patients participating in clinical trials.20

Cost of Care

Another barrier identified in the literature is cost. Several studies have identified a perceived barrier related to the cost involved in implementing palliative care programs in cancer centers. Palliative care programs have struggled to provide cost benefit analysis of their services. Cost savings are a secondary outcome and can be realized when patient preferences are documented and obeyed. Palliative care does not convince patients to follow a conservative plan of care or sign-on to hospice. To the contrary, palliative care practitioners are expert at eliciting the patient’s goals and values and helping integrate them in the treatment plan. Patients may identify not wanting that “last resort” treatment or not wanting to go to the hospital any longer. Some patients may decide they want everything done so they can see their first grandchild born. Patients and families often do not understand that they have a choice in treatments—they may even feel guilty about wanting to stop treatment and expressing this to their oncologist. Also, it is often difficult for patients to tell their own family members that they have had enough treatment and that they would like the focus of their care to be comfort only. Palliative care teams have the skill to advocate for their patients’ preferences and assist the patient in discussing those preferences with their oncologist and family. Aligning treatment with patient goals can also save costs via reduced hospitalizations and by avoiding expensive treatments and procedures that are not aligned with the patient preferences.

In conclusion, there is a strong evidence to support integrating palliative care into cancer centers. However, an understanding of what palliative care is and what it isn’t is crucial for this integration. A majority of patients with cancer consider their disease a “serious illness,” and they will most definitely benefit from a palliative care intervention. A standard approach will also decrease the misunderstanding that palliative care is hospice or EOL care, and ensure that patients benefit from palliative care programs. Early palliative care can prolong survival for some diagnoses, improve QOL, decrease symptom burden, and improve patient and family satisfaction. The example in this paper reviewed some of the challenges that may be encountered during integration, and some solutions to overcome them. As the field of palliative care continues to grow, cancer centers should share examples of how they have successfully integrated palliative care into their centers, so others can learn from their successes and challenges.

Karen Mulvihill, DNP, APRN, FNP-BC, ACHPN, is director of palliative care services at Danbury Hospital.

ACKNOWLEDGEMENT
Thank you to Laurel Halloran, PhD, APRN, for her endless support.

DISCLOSURE
There are no financial conflicts to disclose.

ADDRESS FOR CORRESPONDENCE

Karen Mulvihill, DNP, APRN, FNP-BC, ACHPN
Director, Palliative Care Services
Danbury Hospital
Western Connecticut Health Network

E-mail: Karen.mulvihill@wchn.org
References
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