Palliative care has grown rapidly since about 2000 when it began to be recognized as a specialty. Though it took longer to be adopted in oncology, it is now part of standards for ACOS (American College of Surgeons) for cancer care.
Though most large hospitals have palliative care programs now, the demand for services continues to outweigh the available resources. As more people are realizing the benefits of palliative care, the demand for team services will increase. In talking to palliative care teams around the country, I often hear how they are overwhelmed with requests for consultations. Is this a case of “be careful what you wish for” or an opportunity to restructure how palliative care is provided?
A recent New England Journal of medicine article by Drs. Timothy Quill and Amy Abernethy challenges us to view palliative care on two levels -- the generalist and the specialist -- to create a sustainable model. This article is focused on physicians, but I think it applies to oncology nurses just as well.
The authors recommend the following skillsets:
Primary palliative care skills provided by the oncology team
- Basic pain and symptom management
- Basic management of depression and anxiety
- Basic discussion about goals, prognosis, and suffering
Specialty palliative care provided by the palliative care team
- Management of refractory pain and other symptoms
- Management of more complex depression, anxiety, grief, and existential distress
- Assistance with conflict resolution
- Assistance in addressing futility issues
We know that palliative care benefits patients with advanced cancer and that those that receive the intervention earlier rather than later have better quality of life. So by incorporating basic palliative care services early on by the treating team, the patient reaps the benefits. One of the downsides of referring to palliative care early is that if the palliative care team handles all the basic symptom management, the oncology team may feel that this is not part of their role now, and turf battles about who does what can develop.
How does the oncology team gain these skills? As courses such as ELNEC (End of Life Nursing Education Curriculum) are available to nurses, similar ones can be accessed for physicians and social workers to gain these skills. This would also require the basics of palliative care to be part of all medical and nursing education. There has certainly been improvement in this area in the past decade, but more is needed.
What do you think about this concept? Do you feel comfortable with the basic skill set? How do you access palliative care services and education in your setting?