Blog | Thursday, September 22, 2011

Reducing costs by better integration of palliative care in cancer treatment


We're up to point 9 on the list, and nearing the end, on my review of the article "Bending the Cost Curve in Cancer Care" from the May 26 New England Journal of Medicine. The suggestion from the authors, Drs. Smith and Hillner, is that doctors better integrate palliative care into usual oncology care.

The authors start this important section well: We can reduce patients' fears of abandonment by means of better-integrated palliative care. This topic is fraught with misunderstanding given the references to "death panels" during the recent debate concerning health care legislation ...

Here they're on target: Some patients think, mistakenly, that inclusion of palliative care in their treatment means their doctors are throwing in the towel. I've known some oncologists who think the same, who perceive palliative care as a last resort.

The truth is that palliative care, which aims to relieve symptoms, can be implemented at any point in the treatment of disease.

The authors go on to provide data that cancer patients who receive palliative care live just as long, or longer, than those who don't, and that their medical bills are lower. The issue I have here is their choice of emphasis on a published study of the Aetna Compassionate Care Program in which nurses identified patients for palliative care by administrative claims, "thus bypassing the oncologist." Evidently this strategy led to a doubling of hospice referrals and other possibly good effects.

Besides that the cited study was authored by employees of an insurance company, which I find unpalatable, the concept of having nurses do the referrals deflects the issue: that oncologists talk about palliative care with their patients, directly. Relying on nurses to carry out these conversations would, understandably, contribute to a sense of abandonment, even if the nurses do the job perfectly. A critical role oncologists is to communicate about treatment care options, part of the cognitive work considered in point 8 of this discussion.

But the main idea, that doctors should integrate palliative care into their cancer patients' treatment planning, earlier, and as a supplement and not a replacement for potentially curative or tumor-shrinking strategies, is right on.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.