Palliative Care for All?

The American Society of Clinical Oncology has published a Provisional Clinical Opinion recommending the integration of palliative with standard oncologic care beginning at the point of diagnosis (see Smith, under Palliative and Supportive Care, below). The recommendation is based on the results of seven randomized controlled trials of palliative care plus usual care vs. usual care alone. The most compelling of these, and the one that has received the most attention in both the professional and lay press, is the Temel, et al. article in the New England Journal of Medicine in 2010 that provided "strong evidence" that patients with metastatic non-small cell lung cancer should be offered concurrent palliative and standard care at diagnosis.

Demonstrated benefits, i.e., better patient and caregiver outcomes, of integrating palliative care with standard disease care include better symptom management, improved quality of life for the patient and caregivers, increased use of advance care planning, decreased costs, higher patient satisfaction, reduced caregiver burden, decreased use of emergency rooms and inpatient admissions, and more appropriate use of hospice. An unexpected finding of the Temel study was a possible survival benefit of palliative care integrated with standard care (e.g., chemotherapy). Most of the studies cited in the Provisional Clinical Opinion were small, different models/approaches were used, and some had other methodologic issues. However, none demonstrated harm to any patient in any domain from this approach. Clearly, more research is needed to clarify and refine the role of palliative care at all phases of disease and in multiple settings.

The Provisional Clinical Opinion also provides another authoritative voice to the growing chorus that emphasizes that palliative care, end-of-life-care, and hospice care are not equivalent terms, concepts, or services. End-of-life care and hospice are both subsets of palliative care, with hospice being a specialized approach to end-of-life care largely defined and limited, in this country, by the Medicare Hospice Benefit. The other end of the palliative care continuum is at the time of diagnosis of a life-threatening illness or one with a high symptom burden. At all phases of care, the goal is amelioration or prevention of suffering through symptom management, assistance with defining goals of care and care planning, and improvement in quality of life for the patient and family. Other societies and organizations have called for the integration of palliative care "early in the course of illness" (World Health Organization), "regardless of the state of the disease" (National Consensus Project), and as part of "routine cancer care" (European Society for Medical Oncology) and "comprehensive cancer care" (Society for Surgical Oncology).