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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.

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

There are no financial conflicts to disclose.


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

  1. Cancer program standards: ensuring patient-centered care. 2016;standard 2.4;54. American College of Surgeons website. Accessed October 20, 2016.
  2. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Onc. 2012:30(8):880-887. doi: 10.1200/JCO.2011.38.5161.
  3. Nation Quality Forum. A national framework and preferred practices for palliative and hospice care quality. NQF website. and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx. Published December 2006. Accessed October 15, 2016.
  4. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs: hospice conditions of participation. Federal Register. 2008;73(109). US Government Publishing Office website. https:// Published June 5, 2008. Accessed November 1, 2016.
  5. National Consensus Project for Quality Palliative Care. Clinical practice guidelines for quality palliative care. HPNA website. 3rd_Edition.pdf. Published 2013. Accessed November 1, 2016.
  6. Mulvihill K. Emmi website. dying/. Published October 21, 2014. Accessed October 15, 2016.
  7. Davis MP, Strasser F, Cherny N. How well is palliative care integrated into cancer care? A MASCC, ESMO, and EAPC project. Support Care Cancer. 2015;23(9):2677-2685. doi: 10.1007/s00520-015- 2630-z.
  8. Ferrell B, Sun V, Hurria A, et al. Interdisciplinary palliative care for patients with lung cancer. J Pain Symptom Manage. 2015;50(6):758-767. doi: 10.1016/j.jpainsymman.2015.07.005.
  9. Greer JA, El-Jawahri A, Pirl WF, et al. Randomized trial of early integrated palliative and oncology care. J Clin Onc 2016;34. Suppl 26S; abstr 104.
  10. Temel J, Greer J, Muzikansky A, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl, J Med. 2010;363(8):733-742. doi: 10.1200/JCO.2010.32.4459.
  11. Committee on Approaching Death: addressing key end-of-life issues. Dying in America: improving quality and honoring individual preferences near the end of life. National Academies website. Brief.pdf. Published September 2014. Accessed on October 24, 2016.
  12. Jors K, Seibel K, Bardenheuer H, et al. Education in end-of-life care: what do experienced professionals find important? J Cancer Educ. 2016;31(2):272-278. doi: 10.1007/s13187-015-0811-6.
  13. Horlait M, Chambaere K, Pardon K, Deliens L, Belle S. What are the barriers faced by medical oncologists in initiating discussion of palliative care? A qualitative study in Flanders, Belgium. Support Care Cancer. 2016;24(9):3873-3881. doi: 10.1007/s00520-016-3211-5.
  14. Mahmood LA, Casey D, Dolan JG, Dozier AM, Korones DN. Feasibility of early palliative care consultation for children with high-risk malignancies. Pediatr Blood Cancer. 2016;63(8):1419-1422. doi: 10.1002/pbc.26024.
  15. Balducci L, Dolan D, Hoffe SE, Hoffe SA. Palliative care in older patients with cancer. Cancer Control. 2015;22(4):480-488.
  16. Economou D. Palliative care needs of cancer survivors. Semin Oncol Nurs. 2014;30(4):262-267. doi: 10.1016/j.soncn.2014.08.008.
  17. Tierney DK, Passaglia J, Jenkins P. Palliative care of hematopoietic cell transplant recipients and families. Semin Oncol Nurs. 2014;30(4):253-261. doi: 10.1016/j.soncn.2014.08.007.
  18. LeBlanc TW, O’Donnell JD, Crowley-Matoka M, et al. Perceptions of palliative care among hematologic malignancy specialists: a mixed-methods study. J Oncol Pract. 2015;11(2):e230-e238. doi: 10.1200/JOP.2014.001859.
  19. Donovan KA, Knight D, Quinn GP. Palliative care in adolescents and young adults with cancer. Cancer Control. 2015;22(4):475-479. 20. Sun V, Cooke L, Chung V, Uman G, Smith TJ, Ferrell B. Feasibility of a palliative care intervention for cancer patients in phase I clinical trials. J Palliat Med. 2014;17(12):1365-1368. doi: 10.1089/ jpm.2014.0108.
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