Palliative Care Benefits Are Best With Earlier Initiation in the Cancer Journey

Palliative care is appropriate at any age or any stage of cancer, and should be provided alongside curative-intent care, rather than only after or toward the end of anticancer therapy, reported palliative nurse practitioner Carey Ramirez, ANP-C, ACHPN, manager of advanced practice at the City of Hope in Duarte, California. Ramirez spoke about palliative cancer care at the 2023 Oncology Nursing Society (ONS) Bridge live virtual conference.

“All patients with cancer benefit from palliative care,” Ramirez said. “Supportive care is interdisciplinary, multidimensional, compassionate, holistic, and timely.”

Timing is key, Ramirez emphasized.

“Early referral is important,” he said, noting for example, patients with metastatic non-small cell lung cancer see improved quality of life, improved mood, and even longer survival times with early referrals to palliative support, which lead to less aggressive care and fewer toxicities later on.

“I recommend you create and practice a [communication] process, almost an elevator speech,” he said. “I suggest starting with, ‘we’ll invite our friends from palliative care to add another layer of care’.”

The goals of palliative care can seem ambiguous to patients, especially at first. Some patients worry that palliative or supportive care means they’re no longer eligible for life-saving or life-prolonging care. In reality, hospice is a subset of palliative medicine, and not all palliative care is reserved for the end of life.

Ramirez suggested talking about supportive care in terms of helping patients with their symptoms and pain management. Listening carefully and looking for nonverbal signs of patient anxiety or distress is important.

“We have 2 ears and 1 mouth, and should use them in that proportion,” he said.

If a palliative care consultation is being undertaken when there are still treatment options available to the patient, that should be clearly and explicitly conveyed to patients to alleviate their concerns that their end of life is immediately impending.

“We want them to have the best possible quality of life and … feel well supported on their journey,” Ramirez emphasized.

As the Baby Boomer generation ages into higher cancer risk periods of life, and more people live longer with cancer thanks to early detection and treatment advances, the need for palliative care nurses will grow. There is currently a shortage of palliative specialists and specialists are “maldistributed,” concentrating in urban cancer centers.

“An expansion of primary palliative care capabilities is needed,” he said. “There are organizations and opportunities across the country to enhance your primary palliative care capabilities.”

Examples include Advanced Certified Hospice and Palliative Nurse (ACHPN) training and palliative nurse-practitioner fellowships and certificate programs.

“It is important for all [advanced practice nurses (APRNs) and clinical nurse specialists] to be trained to offer symptom management, to offer psychosocial support, and to do so in a way that aligns with patients’ and families’ goals and values. It’s important to educate them not only about the treatment that is being proposed but about their prognosis,” Ramirez explained.

Nurses who specialize in palliative care lead discussions about patient values and goals, participate in interdisciplinary teams, act as liaisons to advocate for patients, and can help teach other team members about palliative care.

“It’s very important for your patient and family to be on the same page with the attending physician, as well as the APRN involved in their care, with regard to prognosis,” he explained. “It’s important for them to know what their prognosis truly is because it liberates them to make the decisions that are best for them, in accordance with their own goals and values. So please take this responsibility very seriously and work with the attending physician to ensure that patients have an accurate prognosis.”

Advocating for patients and families is imperative.

“We will, at times, spend more time with patients and family than the physician will” he noted. “We’ll also at times be privy to conversations that sometimes patients or families are not comfortable sharing with the physician up front. It’s important for us to advocate on behalf of patients and families even if the direction they want to take is different from that of the oncologist or hematologist.”

Reference

Ramirez C. Palliative care: timing matters. Presented at: ONS Bridge 2023; September 14, 2023.