Kristina N. Michael, APRN, WHNP-BC, Senior Clinical Associate
While the literature shows that early discussions regarding palliative care in the oncology setting are beneficial, significant implementation barriers remain from the patient and provider perspectives. The stigma of palliative care discussion is prevalent and while clinicians have made significant strides to reduce the uneasiness of this important topic, opportunities for growth remain. Early identification and addressing barriers to palliative care conversations can foster a positive experience for both the clinician and the patient. Barriers specific to providers can include time restraints, lack of preparation due to acute clinical changes, fear of negative feedback from patients and/or caregivers, or lack of confidence/skill to appropriately describe the role and tasks of palliative care. Integrating palliative care into treatment and plan-of-care discussions can engage patients and allow them to understand the significance of early dialogue and how it plays into decision making.
A key benefit to patients is discussing their goals of their care prior to any acute episodes or a change in clinical status requiring unexpected decision making. Fatigue, frustration, anxiety, and depression can all play a role on the decision-making process throughout treatment to potentially cloud judgment. It is critical to involve patients in the decision-making process throughout their course of treatment including setting goals and opportunities to optimize their care. The discussion surrounding palliative care requires delicate and thoughtful time and attention and should be regarded as an active and ongoing conversation versus a one-time passive discussion.
One of the strategies utilized by Collins et al. (2022) involved personalizing the conversation and including the following themed discussion points “1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care. Assisting patients to understand how palliative care will be incorporated into their existing care management through symptom management, pain management, and psychological management may reduce any uncertainty or anxiety about future states.
Another strategy that demonstrated improved efficacy was utilizing an institution-based preparation document which promoted accountability, engagement, and active discussion for both the provider and patient. Further consideration to include interventions based on clinical or demographic variables as well as typologies can help relate to the psychological preparedness of patients (Pini et al., 2022). Personalizing this document while adapting to the psychological and physiological differences along the care continuum may result in improved outcomes. Collaboration with multiple disciplines if needed can also support the overall purpose of individualized patient plans.
How can VieCure help? VieCure’s patented artificial intelligence based clinical decision support platform enables codification of clinic policy and procedures on different facets of the care trajectory. For example, when to intervene with a palliative care discussion can be codified in the platform, along with educational tools, assessment tools, rule content and other interventions to facilitate adoption of the clinic’s standard operating procedures. Alerts can be codified in the platform when a patient assessment returns a result that requires clinical intervention to support the patient and manage existing or potential toxicities. Toxicities utilize the CTCAE graded results calculated by the platform which can be actioned through the platform without leaving clinical workflow.
With continued education and targeted interventional programs providers can more confidently manage their patients across the treatment continuum instead of utilizing immediate referrals or external resources. While there is no standard intervention that can be applied to all patients, incorporating these conversations early within the treatment process can show improved outcomes with quality of life, satisfaction of care, improved survival, and even reduction in the healthcare cost burden.
References
Collins, A., Gurren, L., McLachlan, S. A., Wawryk, O., & Philip, J. (2022). Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team. Frontiers in oncology, 12, 1003357. https://doi.org/10.3389/fonc.2022.1003357
S. Pini, H.L. Bekker, M. Bennett, L. Ziegler. (2022). A Structured Intervention to Support Early Palliative Care Conversations for Oncology Patients – A Qualitative Feasibility Study. Clinical Oncology, 34(12), e515-e522. ISSN 0936-6555,
https://doi.org/10.1016/j.clon.2022.05.012.
Kristina Michael, APRN, WHNP-BC
APRN, WHNP-BC, Senior Clinical Associate, Nurse Practitioner, VieCure