ASCO, AAHPM Craft Guidance Statement for Palliative Care

Kathleen Bickel, MD

Palliative care, integrated into routine oncology care, can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, the small workforce of palliative care specialists is insufficient to meet the needs of all patients with cancer, and the services defined as palliative care vary greatly across practices.

In an attempt to combat this problem, ASCO and the American Academy of Hospice and Palliative Medicine (AAHPM) recently partnered to create a consensus definition of high-quality palliative care to be incorporated into oncology practices. The guidance statement is intended to define goals that can help improve the palliative care that is already being delivered by medical oncology practices.

For the project, researchers developed a list of 966 palliative care service items, divided into nine domains, each describing an aspect of palliative care for patients with advanced cancer.

“This is necessary because in order to improve palliative care delivery and access to patients with cancer, we must first define and agree on what oncology practices should be providing,” said lead study author Kathleen Bickel, MD, MPhil, an assistant professor of Medicine at the White River Junction Veterans Affairs Medical Center and the Geisel School of Medicine at Dartmouth, during a press case in advance of the 2015 Palliative Care in Oncology Symposium. “These goals may adapt and change over time, but we hope this work will serve as a foundation for future palliative care—related quality measures, quality improvement initiatives, and educational activities, and will help oncology practices improve their delivery of primary palliative care.”

Thirty-one multidisciplinary panelists—including physicians, nurses, nurse practitioners, social workers, and patient advocates—used a modified Delphi methodology to rank each item according to importance, feasibility, and scope.

The highest consensus among panelists was in favor of including end-of-life care (81%), communication and shared decision making (79%), and care planning (78%).

Under the appropriate palliative care and hospice referral domain (69% consensus), panelists agreed that oncology practices should be able to explain the difference between palliative care and hospice care to patients. They also agreed that oncologists should refer patients with an expected survival of under 3 months to hospice.

In the largest domain with 259 items, symptom assessment and management (66%), there was a consensus that symptoms should be assessed and managed at a basic level with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, and pain.

Other domains were career support (56%), coordination/continuity of care (48%), psychosocial assessment and management (39%), and spiritual and cultural assessment and management (35%).

The guidelines created from this research, should make it easier for oncologists improve on palliative services they are already providing, said Bickel.

“Oncologists can and already do provide many palliative services, but until now, no comprehensive guidance existed on what practices should be aiming for,” she said. “For the first time, we’ve set some reasonable and achievable goals for high-quality primary palliative care delivery for oncology practices in the everyday care of patients, which we hope will improve patient comfort and quality of life.”

Bickel added that it will take time for the guidelines to be implemented in oncology practices, but concluded that they may be useful for providers looking to improve palliative care delivery.

“This collaboration between professional organizations is a significant step toward accessible, high-quality palliative care for all patients,” said Don S. Dizon, MD, ASCO Expert and presscast moderator, in a statement. “The recommendations will help us identify essential palliative care services and set achievable goals for medical oncology practices across the country.”

Bickel KE, McNiff KK, Buss MK, et al. Defining high-quality palliative care in oncology practice: An ASCO/AAHPM Guidance Statement. J Clin Oncol 33, 2015 (suppl 29S; abstr 108).