Integrating palliative care for patients with cancer
Dy, 2017Hui, 2016Hui, 2019Moreno-Alonso, 2018Pieniazek, 2020
Patients with cancer that is or at risk of becoming chronic, progressive or recurrent, particularly those with advanced or life-limiting disease, often have significant needs and can benefit from a needs-focused palliative approach to care alongside disease-orientated management, regardless of prognosis. Palliative care may involve referral to a specialist palliative care service. Principles of palliative care for patients with cancer summarises the principles of palliative care for patients with cancer.
Collaborate with, and define the roles and responsibilities of, clinicians, services, families and carers. Consider whether or when to refer to a specialist palliative care service—see Who provides palliative care?.
Educate the patient and their carer(s) about the prognosis, if appropriate—see Overview of communicating with and supporting patients with palliative care needs.
Discuss the patient’s preferences, values and goals of care initially and continue to review.
Support early and ongoing advance care planning, including discussion of resuscitation and hospitalisation.
Identify and support emotional and psychosocial needs.
Anticipate and plan for transitions across various settings, and acknowledge patient and family preferences—see Where is palliative care provided?.
Create and maintain an individualised disease management plan to address current health problems and those expected to arise:
- Manage symptoms and complications of cancer and its treatment.
- Plan an approach to modify or stop treatments if or as the cancer progresses (see Decisions about withdrawing or withholding treatment in palliative care), including drugs.
Support the family and principal carer.
Support patients and their families and carers experiencing loss, grief and bereavement.
Prepare for the last days of life.
NB1: It is often appropriate to introduce palliative care from the time it is recognised that a patient has progressive, life-limiting illness; palliative care can be continued alongside disease-orientated management.
NB2: Aspects of palliative care may need to be introduced or revisited depending on patient and carer needs, and the clinical context. The approach and priorities of care often change with the phase of the illness.
NB3: Caring for patients with palliative care needs can be personally and professionally demanding—for further information and advice on building resilience and avoiding burnout, see Healthcare professional wellbeing in palliative care.
It is preferable to introduce palliative care early alongside disease-orientated management for patients with cancer because this:
- improves symptom management and quality of life
- helps clarify goals of care and care decisions
- optimises communication and the family’s experience
- may improve survival.
For general benefits of introducing palliative care early, and considerations to inform the approach, see Introducing a patient to palliative care.
Estimating prognosis in cancer is complex. The trajectory of cancer depends on the type (and subtype) of cancer and effectiveness of available treatments. Advances in cancer treatment (particularly immunotherapy and stem cell transplantation for haematological cancersMitchell, 2018) have changed the trajectory of some cancers; in some cases, the time before deterioration and death has been significantly prolonged. The best approach to early integration of palliative care alongside these newer or aggressive treatments remains under investigation, but this does not exclude patients with cancer considering or undergoing such treatments from being offered early palliative care. The increasing number of options for cancer management highlights the importance of iterative discussions of goals of care and advance care planning.
[NB1] [NB2] [NB3]
progressive, advanced or metastasising cancer
poor functional or performance status as measured with a validated tool, such as the AKPSAbernethy, 2005 or ECOG Performance Status ScaleJang, 2014
frailty that prohibits anticancer therapy
symptoms or complications, such as breathlessness, delirium, cognitive change or anorexia–cachexia syndrome
evidence of a systemic inflammatory response, such as elevated CRP concentration, low albumin concentration or leucocytosis
AKPS = Australia-modified Karnofsky Performance Status; CRP = C-reactive protein; ECOG = Eastern Cooperative Oncology
NB1: Also consider general factors when deciding if a patient requires palliative care; see Introducing a patient to palliative care.
NB2: Also consider when or if to refer to a specialist palliative care service; prompts to consider specialist palliative care service involvement are outlined in Specialist palliative care services.
NB3: A variety of tools can assist in quantifying these indicators, and supplement clinician predictions of survival and changes in illness trajectory. There is no gold-standard tool, but the Palliative Prognostic Score (PaP)Stone, 2021 and Palliative Prognostic Index (PPI) are widely used and particularly useful in the last months of life. Biomarker-based tools such as the Glasgow Prognostic Score may also be useful in some contexts.