Kathleen Bickel

Defining High-Quality Palliative Care in Oncology Practice: An American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine Guidance Statement

PURPOSE Integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to specialist palliative medicine. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices. METHODS An expert steering committee outlined 966 palliative care service items, in nine domains, each describing a candidate element of primary palliative care delivery for patients with advanced cancer or high symptom burden. Using modified Delphi methodology, 31 multidisciplinary panelists rated each service item on three constructs: importance, feasibility, and scope within medical oncology practice. RESULTS Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision Making (79%); and Advance Care Planning (78%). The lowest proportions were in Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level, with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea, and pain. Within the Appropriate Palliative Care and Hospice Referral domain, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients appropriately. CONCLUSION This statement describes the elements comprising high-quality primary palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find this information useful to inform operational changes and quality improvement efforts.

Death Rattle and Oral Secretions—Second Edition #109

1. Ruggiero S, Gralow J, Marx RE, Hoff AO, Schubert MM, Huryn JM, Toth B, Damato K, Valero V: Practical guidelines for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients with cancer. J Clin Oncol Practice 2006;2:7–14. 2. Cavanna L, Bertè R, Arcari A, Mordenti P, Pagani R, Vallisa D: Osteonecrosis of the jaw. A newly emerging site-specific osseous pathology in patients with cancer treated with bisphosphonates. Report of five cases and review of the literature. Eur J Intern Med 2007;18:417–422. 3. Weitzman R, Sauter N, Eriksen EF, Tarassoff PG, Lacerna LV, Dias R, Altmeyer A, Csermak-Renner K, McGrath L, Lantwicki L, Hohneker JA: Critical review: updated recommendations for the prevention, diagnosis, and treatment of osteonecrosis of the jaw in cancer patients—May 2006. Crit Rev Oncol Hematol. 2007;62:148–152. 4. Kademani D, Koka S, Lacy MQ, Rajkumar SV: Primary surgical therapy for osteonecrosis of the jaw secondary to bisphosphonate therapy. Mayo Clinic Proc 2006;81:1100–1103. 5. Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons: American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonaterelated osteonecrosis of the jaws. J Oral Maxillofac Surg 2007;65:369–376. www.aaoms.org/docs/position_papers/ osteonecrosis.pdf (Last accessed September 30, 2007). 6. Myeloma Minute: Special Advisory on Osteonecrosis of the Jaws. International Myeloma Foundation. http://myeloma. org/main.jsp?type article&tab_id 1&menu_id 0&id 1223 (Last accessed September 30, 2007). 7. Diel IJ, Fogelman I, Al-Nawas B, Hoffmeister B, Migliorati C, Gligorov J, Väänänen K, Pylkkänen L, Pecherstorfer M, Aapro MS: Pathophysiology, risk factors and management of bisphosphonate-associated osteonecrosis of the jaw: Is there a diverse relationship of aminoand non-aminobisphosphonates? Crit Rev Oncol Hematol 2007;64:198–207.

Oncologists' End of Life Treatment Decisions: How Much Does Patient Age Matter?

Background: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists’ attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists’ perspectives on how patient age affects their treatment decisions. Methods: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. Results: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. Discussion: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists’ chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.

Enhancing Informed Consent for Physician Aid in Dying: Potential Role of Handout on Possible Benefits of Palliative Care.

In the United States, physician aid in dying (PAD) is now legal in several states. However, neither a requirement for a palliative care (PC) consultation nor a defined education in PC exists for physicians participating in PAD or patients requesting assistance. Patients with advanced chronic and serious illness often experience complex physical, psychosocial, and spiritual distress. PC focuses on relieving this distress and improving patient quality of life through early identification and intervention in all domains of suffering, including physical, psychological, social, and spiritual. Ideally, we would recommend a PC consult, but unfortunately, PC is not readily available or offered at this time to all those who might benefit from it. We present a case for providing an educational handout to patients who inquire about PAD. This handout explains the potential benefits of PC as an additional procedural safeguard to existing regulations. Such information would help to ensure the integrity of the informed consent process, enhance shared decision making, and improve patient comprehension of the options.

Defining high-quality palliative care in oncology practice: An ASCO/AAHPM Guidance Statement.

108 Background: When integrated into routine oncology care, palliative care can improve symptom burden, quality of life, and patient and caregiver satisfaction. However, not all oncology practices have access to subspecialty palliative medicine for referral. This project endeavored to define what constitutes high-quality primary palliative care as delivered by medical oncology practices. METHODS An expert steering committee developed a list of 966 palliative care service items, divided into nine domains, each describing an aspect of palliative care delivery for patients with advanced cancer. Using a modified Delphi methodology, 31 multi-disciplinary panelists ranked each service item according to importance, feasibility and scope. RESULTS Panelists endorsed the highest proportion of palliative care service items in the domains of End-of-Life Care (81%); Communication and Shared Decision-Making (79%); and Care Planning (78%). Lowest proportions were in: Spiritual and Cultural Assessment and Management (35%) and Psychosocial Assessment and Management (39%). In the largest domain, Symptom Assessment and Management, there was consensus that all symptoms should be assessed and managed at a basic level with more comprehensive management for common symptoms such as nausea, vomiting, diarrhea, dyspnea and pain. Under the domain of Appropriate Palliative Care and Hospice Referral, there was consensus that oncology practices should be able to describe the difference between palliative care and hospice to patients and refer patients with an expected survival of under 3 months or poor performance status (Zubrod 3-4) to hospice. CONCLUSIONS This statement describes high-quality palliative care for patients with advanced cancer or high symptom burden, as delivered by oncology practices. Oncology providers wishing to enhance palliative care delivery may find the guidance useful to inform operational changes and quality improvement efforts.

Consensus development: Within general oncology practice, what constitutes high-quality palliative care delivery?

280 Background: Multiple studies illustrate the benefits of combined palliative and standard cancer care, but oncology practices need guidance to fill existing gaps in delivering high quality palliative care (PC) to cancer patients. As a first step, ASCO and the American Academy of Hospice and Palliative Medicine (AAHPM) sought to develop a consensus definition of which PC aspects are within the purview of general adult oncology practice in the United States. METHODS An ASCO and AAHPM steering group used existing publications to define 9 domains of PC in oncology: Symptom Assessment and Management (A&M), Psychosocial A&M, Spiritual and Cultural A&M, Communication and Shared Decision-Making, Care Planning, Appropriate Palliative Care and Hospice Referral, Coordination and Continuity of Care, Carer Support, and End-of-Life Care. Within each domain, key PC activities were itemized and described (e.g. pain assessment using a standardized scale at every clinical encounter), totaling 966 activities. A 31-member multidisciplinary panel participated in a modified RAND Delphi process, rating each activity on a 9-point scale according to 3 constructs: importance, feasibility, and scope of practice. Composite scoring categorized activities as either reasonably within scope of oncology practice, uncertain, or typically not in scope. RESULTS The response rate for each round was 94%. Notable panelist concerns included the breadth of palliative care practice, the varied access that oncology practices have to PC resources, and the varied individual knowledge and comfort with specific activities. Despite multiple small ranking changes between surveys, only 41 activities changed in scope of practice category. Of 966 activities, 62% were ranked as reasonably within scope of oncology practice, 36% were uncertain, and 2% were typically not in scope. CONCLUSIONS Despite the diverse range of PC activities, panelists strongly agreed that more than half were reasonably within the scope of adult medical oncology practice. These items provide a foundation for improving palliative care delivery within an oncology practice, with suggestions for future performance measures and quality improvement activities.