1. DiGiulio, Sarah

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It was as recently as 2012 that ASCO issued its first guidance on integrating palliative care as a standard part of oncology care. And in a clinical practice guideline update released earlier this year, ASCO revised its recommendations based on new evidence (J Clin Oncol 2017;35:96-112).

Betty Ferrell, RN, P... - Click to enlarge in new windowBetty Ferrell, RN, PhD. Betty Ferrell, RN, PhD

"A key emphasis is the need to integrate palliative care much earlier in the course of illness and treatment," explained the update's lead author Betty Ferrell, RN, PhD, Director and Professor in the Division of Nursing Research and Education in the Department of Population Sciences at City of Hope, Duarte, Calif. "These guidelines reflect a growing body of solid evidence for the benefits of palliative care to improve patient quality of life.


"This version also emphasizes that [palliative care] should be provided by the oncology team as well as the [palliative care] specialty service," Ferrell said.


Key recommendations from the expert panel who wrote the guidelines (based on a systematic review of literature) that were included in the updated guidelines include the following:


* All patients with advanced cancer-whether patient or outpatient-should receive palliative care services early in the course of their treatment, concurrent with active treatment.


* For newly-diagnosed patients with advanced cancer, referral to palliative care services should happen with 8 weeks of diagnosis.


* Essential components of palliative care services may include symptom, distress, and functional status management (such as pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation); clarification of treatment goals; exploration of understanding and education about illness and prognosis; assessment and support of coping needs; coordination with other care providers; and referral to other care providers, if needed.



The new guideline makes it clear that these palliative care services can be provided by an interdisciplinary palliative care team or by the patients' nurses, social workers, or other providers. What's important is that all patients with advanced cancers have access to these services.


Ferrell elaborated on why the revisions are important and the barriers still standing in the way of more comprehensive palliative care services for patients with cancer.


1 Why were these palliative care guidelines updated most recently?

"The health care system is so burdened with limited resources, and we need new models of care. In previous years, [palliative care] was seen as only indicated at the end of life. However, there is growing awareness that all patients experience symptoms and [quality of life] concerns that would benefit greatly from [palliative care].


"There is also an important issue of the aging of our population. Our cancer patients are older and they come with many comorbidities [that are] also compromising their quality of life. And finally, improved cancer treatment means that patients live much longer, even those with advanced disease. We need to support our patients who now are living years with significant quality of life concerns.


2 The oncology community has been talking about the importance of palliative care for several years-are we there yet, and what are barriers that still impede efforts to make these services more widely available?

"We have made significant progress. There is broad acceptance across most oncology settings that palliative care is essential to quality oncology care.


"Barriers remain, however. Patients and families are often reluctant to accept palliative care as they associate it with end-of-life care. Unfortunately, patients are often not referred for palliative care until very late, and referrals to hospice come even later. There is a major need to increase palliative care knowledge and skill in the entire oncology workforce as all clinicians practicing in the field of oncology need [a] generalist level of competence in palliative care.


"The key paradigm shift [over the past 5 years, since the first guidelines were developed,] is that palliative care is now firmly established as a specialty in medicine, nursing, and other disciplines. There is also a very substantial body of evidence supporting the benefits of palliative care to health systems and to patients."


3 What is the bottom line about these updated guidelines and providing palliative care services to patients with cancer?

"Palliative care improves quality of life for patients, supports family caregivers, extends survival, and benefits health care systems.


"Palliative care is important for all cancer patients across the care trajectory."