Early palliative care can cut hospital re-admissions for cancer patients

Norman Swan: There's still a lot of fear around the phrase 'palliative care'. We link it to imminent death. An experiment in changing the way care is given to people with cancer has shown that this link to death need not be so, although the fear is still there, at least amongst doctors.

Richard Riedel is a medical oncologist (a cancer specialist) at Duke University Medical Center in North Carolina.

Richard Riedel: In looking at our cancer patients that were admitted to hospital, it was clear that they had a significant symptom burden, and we were challenged by the sense that patients were often readmitted for repeat symptoms that were inadequately controlled.

Norman Swan: Such as?

Richard Riedel: Pain, nausea, vomiting, symptoms related to treatment or complications of their disease itself.

Norman Swan: Across the board?

Richard Riedel: Across the board, yes.

Norman Swan: That's a common problem internationally.

Richard Riedel: I think that's true. I think certainly for patients with advanced cancer, and I would say three-quarters of the patients that are admitted to our inpatient ward have advanced cancer, what comes with them is a significant symptom burden.

Norman Swan: So what did you try to do to solve the problem?

Richard Riedel: We partnered with our palliative care colleagues who previously played a very limited role on our inpatient oncology service, and we partnered with them to bring their skill and expertise to our inpatient ward on a daily basis. That is in stark contrast to where we were before where all patients were managed by one medical oncologist. We created a scenario where we now not only had a medical oncologist but a palliative care trained hospitalist who, in conjunction with a medical oncologist, would help care for the patients on the inpatient ward.

Norman Swan: Because it's one of the misconceptions about palliative care, is that people think that palliative care is for the last two weeks of life and it's about morphine, when in fact what palliative care physicians are really good at is improving the quality of life of people with cancer and indeed other conditions, sometimes years away from the time that you might die.

Richard Riedel: I think that's very true, and I think the perception that many patients have is in part due to an inappropriate effort on the part of physicians not to get hospice involved early enough. There is an increasing trend in recognition now that early intervention with palliative care has the potential to impact patients in a good way.

Norman Swan: I think Australian research has shown that you extend survival.

Richard Riedel: Australian data, and there's also data from Jennifer Temel in a study published in lung cancer showing that early intervention with palliative care improves survival as well.

Norman Swan: Did you have any resistance…before we get to the results, did you get any resistance from patients saying, 'My God, you think I'm going to die in a month's time if you are getting me to see a palliative care physician'?

Richard Riedel: We had a lot of concern about what the perception would be, not only on behalf of the patients but also on behalf of our medical oncology colleagues. We don't make an active effort to introduce the provider as a palliative care physician, we will introduce them the same way I introduce myself; I'm a partner with your outpatient oncologist. And the title itself is less important.

Norman Swan: So to make it tangible for the person listening to us, give me a typical patient journey into your ward, the way it was and the way it is now and how it's different.

Richard Riedel: So the way it was prior to 2007 is that all patients admitted to the inpatient ward were under the supervision of a medical oncologist, and it was the medical oncologist's job to see each patient daily, make treatment plans and follow them through the duration of their hospitalisation. What we do currently is all patients who are admitted to the inpatient ward are discussed in sort of multidisciplinary rounds with both the medical oncologist and palliative care physician, and then there is a determination made as to who the attending of record would be, who would best serve the needs of the patient.

Norman Swan: Who's the doctor that's going to take charge.

Richard Riedel: That's correct. And so in some cases it's the medical oncologist, in other cases it's the palliative care physician, but importantly we have touch-down points throughout the day where the team will meet as a whole with both attendings being present…

Norman Swan: And when you say 'attendings', that's the American for what we would call consultants.

Richard Riedel: Yes. And there would be a discussion regarding the needs of the patient, and it allows for both formal and informal consultation between the medical oncologist and palliative care physician in terms of how to best move the care of the patient forward. Not every patient will necessary see the palliative care provider, but the palliative care provider is present and can provide input for all patients.

Norman Swan: They might advise the medical oncologist; this is what you need to do about their constipation, this is what you need to do about their pain or their nausea or their depression.

Richard Riedel: That's correct.

Norman Swan: What were the results?

Richard Riedel: What we were able to show is that…in a cohort that was studied during a time period after approximately one year of implementation we were able to show that the presence of the palliative care group in conjunction with the medical oncologist decreased the length of stay for patients by a little less than half a day. We were also able to show that our seven-day and 30-day re-admission rates were significantly decreased. We are able to show that ICU transfers were decreased, although that was not statistically significant.

Norman Swan: So in other words you kind of interrupted a pathway to serious illness.

Richard Riedel: We'd like to think so. And lastly we were able to show that hospice referrals increased in the post-intervention period, again not statistically significant, the numbers were small, but I think certainly showing a trend toward benefit.

Norman Swan: And what did people with cancer think about it?

Richard Riedel: Again, I think the patients themselves I don't think were fully aware of the fact that we have this process ongoing. They see a single provider who comes to them daily who cares for them and works with their outpatient provider, but I don't think they have a full understanding of the logistics involved.

Norman Swan: So they don't know they are being looked after by a palliative care physician.

Richard Riedel: I think many of them don't.

Norman Swan: To Australian ears that sounds like a lack of transparency in terms of the patient involvement in their own care.

Richard Riedel: I think it can be perceived like that, and certainly we are not in a position to hide that from patients, and certainly if they ask, we are open and honest about the issue. I think the reality is most patients recognise that they have a significant symptom burden, and it doesn't matter who is taking care of them, if their symptoms are getting better I think they are pleased.

Norman Swan: Let's talk about the cancer specialists, because one of the problems, at least in Australia and I suspect is true in the United States, is that the biggest barrier to palliative care referrals are the cancer specialists themselves who might be on their fourth round of chemo and they have deluded themselves into thinking they are still giving curative care when in fact, as a cancer specialist, you've been delivering palliative care for three years and just not admitting it to yourself.

Richard Riedel: I think that's fair. I think for too long we've been so focused…and generally speaking I think medical oncologists are so focused on attacking the cancer, I think there is, again, increasing recognition that we can do better, and that by having our palliative care colleagues as an additional layer of support early on in the disease course, we have the potential to provide more meaningful impact.

Norman Swan: So is the model spreading?

Richard Riedel: I think there has certainly been a lot of interest nationally about the model, and we actually have had some interest internationally as well, just to make sure that people…for individuals to gain a better understanding of how we actually do it.

Norman Swan: A lot of chemotherapy now is done on an outpatient basis, so people don't get admitted to hospital, and if they get their symptoms they are often re-admitted for the day just to…you know, a day clinic to get their symptoms sorted out, but not with a palliative care physician attached. What are you doing in your outpatient clinics when people don't get admitted but they have a symptom burden? Are you going to integrate palliative care into a standard chemotherapy clinic?

Richard Riedel: We've actually done that already. So we have an outpatient palliative care clinic that provides coverage about five days a week and it started just a couple of years ago and has quickly expanded. Again, we have the layer of support on the inpatient realm and we've complimented that with the outpatient clinic as well.

Norman Swan: Richard Riedel is a medical oncologist at Duke University Medical Center in North Carolina.