Start Discussions About Palliative Care Upon Initial Metastatic Diagnosis

Tony Berberabe, MPH @OncBiz_Wiz | August 11, 2015
Michael Rabow, MD

Michael Rabow, MD

Palliative care generally refers to patient and family-centered care that optimizes quality of life by anticipating, preventing, and alleviating suffering across the duration of a patient’s illness. Historically, palliative care referred to treatment available to patients at the end of life who were enrolled in hospice. More recently, palliative care has become available to seriously ill patients regardless of their prognosis. In addition, its meaning has evolved to encompass comprehensive care that may be provided along with disease-specific, life-prolonging treatment.

In the 10 years since the establishment of The National Consensus Project for Quality Palliative Care, a program established to create clinical practice guidelines that improve the quality of palliative care in the United States, the number of hospice programs has increased by 56.5% and non-hospice palliative care programs have increased by 148% in hospitals with over 50 beds.1,2 In 2013, there were approximately 1.1 million deaths occurring under the care of one of over 5000 hospices.1 Palliative care services have expanded similarly across hospital and community care settings, including acute care units, emergency and critical care departments, outpatient settings, and within innovative community programs for patients with chronic conditions, such as neurological, cardiac, and pulmonary disease.3

There are many myths associated with palliative care including that it can only be provided in a hospital and that pain medications used in palliative care lead to addiction. Perhaps the biggest myth is that palliative care represents a resignation or a form of “giving up” by the healthcare provider and signals the beginning of end-of-life care to the patient. The reality is that high-quality palliative care is focused on pain management, control of symptoms, and helping patients reach their specific treatment goals.

The goal of palliative care is improved quality of life for patients and their loved ones. In the urologic oncology field, urologists can play an important role in successful comprehensive care by incorporating palliative care in their treatment regimens.

“Patients should be aware of palliative care options right from the beginning of their diagnosis and treatment,” said Michael Rabow, MD, the Hellen Diller Family Chair of Palliative Care at the University of California San Francisco, Hellen Diller Family Comprehensive Cancer Center. “Palliative care is not just end-of-life care, it is not just limited to patients who are dying.”

The key begins with the urologist, said Rabow, who is professor of clinical medicine and urology. By making palliative care a part of routine urologic care, and especially in cancer care, it can prevent or alleviate, as early as possible, the symptoms and side effects of treatment associated with the disease. The objective of palliative care is not to cure but it should be provided alongside curative treatment. Palliative care is sometimes referred to as comfort care, supportive care, and symptom management.

“As urologists, we need to change our habits so that we can honestly tell patients that part of providing comprehensive care for prostate or renal cancer involves palliative care,” said Rabow. A frank discussion about palliative care should be initiated when the patient’s course of treatment is discussed.

The American Society of Clinical Oncology has come out clearly stating that any patient with metastatic cancer or very high symptom burden should be receiving concurrent palliative care and oncologic care as standard therapy.

“We know that in medicine, once we have good evidence of what we should do, it takes 17 years for it to become standard practice,” said Jonathan Bergman, MD, an assistant professor of urology and family medicine at the Veterans Health Affairs of Greater Los Angeles and the David Geffen School of Medicine at UCLA. “That’s not acceptable. We need to find ways to implement interventions much faster and much more broadly, once we are sure that it’s the right thing do.”

Rabow suggests that one way to incorporate palliative care into the comprehensive care regimen might be to think about palliative care like nutrition or other supportive interventions. The urologist can position the benefits of palliative care and referral to a palliative care specialist in a similar way that nutrition is positioned: As the patient undergoes urologic treatments, the urologist can make concurrent recommendations about nutrition directly, or refer to a nutritionist.


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