Early Specialty Palliative Care

N Engl J Med 2014; 370:1074-1076 

March 13, 2014DOI: 10.1056/NEJMc1400243

Article

To the Editor:

We concur with the Sounding Board article by Parikh et al. (Dec. 12 issue)1 and believe that additional barriers to access to palliative care deserve mention and may or may not be amenable to change in the short term.2 Oncologists may not refer patients because of personal biases. In addition, the palliative care team itself can sometimes be an obstacle — referrals will continue only if recommendations are thought to be valuable. Furthermore, screening to identify patients who will benefit from palliative care is an issue: oncologists may be aware of the benefits of palliative care and open to referral but lack the ability to identify patients in need of referral. As we3,4 and others5 have shown, application of screening guidelines6 with little lead time in both the outpatient and inpatient settings may have an effect. Finally, we have piloted application of the “bundles” concept to palliative care referrals in the intensive care unit. By using ventilator withdrawal as the trigger for a consult, we increased the number of earlier referrals. Such screening tools may enable the busy yet caring oncologist to quickly identify patients who might benefit from palliative care services.

Paul Glare, M.D.
Andrew S. Epstein, M.D.
Stephen M. Pastores, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY
pastores@mskcc.org

No potential conflict of interest relevant to this letter was reported.
6 References

To the Editor:

Several clinical trials have shown the benefit of early specialty palliative care in advanced cancer, with improved symptom control, satisfaction with care, quality of life, and possibly survival at reduced cost.1-3 Parikh and colleagues highlight the commonly held misperception that palliative care is synonymous with end-of-life care as a key barrier to the implementation of an integrated palliative care–oncology pathway. Although oncologists agree that early referral to palliative care is ideal, studies consistently show that patients continue to be referred late, often close to the end of life, and only after all anticancer treatments have been exhausted.4 Palliative care training for medical oncologists has the potential to improve this trend. Since 2003, the European Society for Medical Oncology has been leading the way by formally accrediting centers of integrated oncology and palliative care. A similar initiative by the American Society of Clinical Oncology would serve as a catalyst for the implementation of the more optimum care outlined in the Sounding Board article.

Jodie E. Battley, M.B., B.Ch.
Louise C. Connell, M.B., B.Ch.
Seamus O'Reilly, M.D., Ph.D.
Cork University Hospital, Cork, Ireland
jebattley@gmail.com

No potential conflict of interest relevant to this letter was reported.
4 References

The authors reply: As Glare et al. note, screening1 and practice2 guidelines for oncologists to identify patients in need of referral to specialty palliative care do exist. Such guidelines have proved to be successful in identifying seriously ill patients who are at high risk for early death and who should be a priority for earlier palliative care.3 These measures may be useful to reduce the staggering rates of late referrals for palliative care, as described by Battley et al. However, although practice changes and education may reduce practitioners' resistance to early palliative care, these advances must be accompanied by system-level changes. For example, reimbursement structures should provide incentives for advance care planning and palliative care consultations early in the course of illness. Some institutions have even implemented quality-improvement initiatives that tie evidence-based palliative care screening to pay-for-performance reimbursement.4 These initiatives have tripled the rates of early palliative care consultation in target populations. Only through such a coordinated strategy can we ensure that the benefits of early specialty palliative care are fully realized in tomorrow's health care system.

Ravi B. Parikh, A.B.
Harvard Medical School, Boston, MA
Jennifer S. Temel, M.D.
Massachusetts General Hospital, Boston, MA
jtemel@partners.org

Since publication of their article, the authors report no further potential conflict of interest.