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 This is an original JCO publication from 2016. Please visit the JCO website to access the full article.


Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline



 Authors
Betty R. Ferrell, Jennifer S. Temel, Sarah Temin, Erin R. Alesi, Tracy A. Balboni, Ethan M. Basch, Janice I. Firn, Judith A. Paice, Jeffrey M. Peppercorn, Tanyanika Phillips, Ellen L. Stovall,† Camilla Zimmermann, and Thomas J. Smith

THE BOTTOM LINE

Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update

Guideline Question

Should palliative care concurrent with oncology care be standard practice?

Target Population

Patients with advanced cancer and their caregivers

Target Audience

Oncology clinicians, patients, caregivers, and palliative care specialists

Methods

An Expert Panel was convened to update clinical practice guideline recommendations based on a systematic review of the medical literature.

Key Recommendation

Patients with advanced cancer, whether patient or outpatient, should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referring patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer caregivers of patients with early or advanced cancer to palliative care services.

Specific Recommendations

Patients with advanced cancer should be referred to interdisciplinary palliative care teams (consultation) that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer (type: evidence based, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: strong).

Palliative care for patients with advanced cancer should be delivered through interdisciplinary palliative care teams with consultation available in both outpatient and inpatient settings (type: evidence based, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate).

Patients with advanced cancer should receive palliative care services, which may include referral to a palliative care provider. Essential components of palliative care may include:

  • Rapport and relationship building with patients and family caregivers
  • Symptom, distress, and functional status management (eg, pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation)
  • Exploration of understanding and education about illness and prognosis
  • Clarification of treatment goals
  • Assessment and support of coping needs (eg, provision of dignity therapy)
  • Assistance with medical decision making
  • Coordination with other care providers
  • Provision of referrals to other care providers as indicated

For newly diagnosed patients with advanced cancer, the Expert Panel suggests early palliative care involvement within 8 weeks of diagnosis (type: informal consensus, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate).

Among patients with cancer with high symptom burden and/or unmet physical or psychosocial needs, outpatient cancer care programs should provide and use dedicated resources (palliative care clinicians) to deliver palliative care services to complement existing program tools (type: evidence based, benefits outweigh harms; evidence quality: intermediate; strength of recommendation: moderate).

For patients with early or advanced cancer for whom family caregivers will provide care in the outpatient setting, nurses, social workers, or other providers may initiate caregiver-tailored palliative care support, which could include telephone coaching, education, referrals, and face-to-face meetings. For family caregivers who may live in rural areas and/or are unable to travel to clinic and/or longer distances, telephone support may be offered (type: evidence based; evidence quality: low; strength of recommendation: weak).

Qualifying Statement

This guideline uses the National Consensus Project definition of palliative care: “Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.” 3(p9)

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate. Patients in clinical trials may benefit from the support of palliative care.

Additional Resources

More information, including a Data Supplement with additional evidence tables, a Methodology Supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/palliative-care-guideline and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

SUMMARY OF RECOMMENDATIONS

Clinical QuestionRecommendationEvidence Rating
What is the most effective way to care for patients with advanced cancers’ symptoms (palliative care services in addition to usual care, compared with usual care alone)?Patients with advanced cancer should be referred to interdisciplinary palliative care teams (consultation) that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer.

Type: evidence based, benefits outweighs harms

Evidence quality: intermediate

Strength of recommendation: strong

What are the most practical models of palliative care? Who should deliver palliative care (external consultation, internal consultations with palliative care practitioners in the oncology practice, or performed by the oncologist him- or herself)?Palliative care for patients with advanced cancer should be delivered through interdisciplinary palliative care teams, with consultation available in both outpatient and inpatient settings.

Type: evidence based, benefits outweigh harms

Evidence quality: intermediate

Strength of recommendation: moderate

How is palliative care in oncology defined or conceptualized?Patients with advanced cancer should receive palliative care services, which may include a referral to a palliative care provider. Essential components of palliative care include:

Type: informal consensus

Evidence quality: intermediate

Strength of recommendation: moderate

Rapport and relationship building with patient and family caregivers

Symptom, distress, and functional status management (e.g., pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation)

Exploration of understanding and education about illness and prognosis

Clarification of treatment goals

Assessment and support of coping needs (e.g., provision of dignity therapy)

Assistance with medical decision making

Coordination with other care providers

Provision of referrals to other care providers as indicated

For newly diagnosed patients with advanced cancer, the Expert Panel suggests early palliative care involvement, starting early in the diagnosis process and ideally within 8 weeks of diagnosis.
How can palliative care services relate in practice to other existing or emerging supportive care services (including nurse navigation, lay navigation, community and home health care, geriatric oncology, psycho-oncology, and pain services)?Among patients with cancer with high symptom burden and/or unmet physical or psychosocial needs, outpatient programs of cancer care should provide and use dedicated resources (palliative care clinicians) to deliver palliative care services to complement existing program tools.

Type: informal consensus, benefits outweigh harms

Evidence quality: intermediate

Strength of recommendation: moderate

Which interventions are helpful for family caregivers?For patients with early or advanced cancer for whom family caregivers will provide care in outpatient, home, or community settings, nurses, social workers, or other providers may initiate caregiver-tailored palliative care support, which could include telephone coaching, education, referrals, and face-to-face meetings. For family caregivers who may live in rural areas and/or are unable to travel to clinic and/or longer distances, telephone support may be offered.

Type: evidence based

Evidence quality: low

Strength of recommendation: weak

  



ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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