Integrative and Palliative Medicine Synergy: Structures and Solutions

Abstract

Cancer patients and survivors often experience high symptom burden well addressed by integrative oncology (IO) and palliative medicine (PM). IO is “evidence-based cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications alongside conventional cancer treatments to optimize health, quality of life, and clinical outcomes.”¹ IO is distinct from alternative medicine that is used instead of conventional treatments.² PM “improves quality of life for patients and families during life-threatening illness through prevention and relief of pain and other physical, psychosocial, and spiritual problems.”³

These definitions reveal common philosophies among both fields, which emphasize interdisciplinary person-centered care to enhance quality of life and reduce suffering.⁴ Cancer and its treatments are often associated with fatigue, pain, neuropathy, nausea and vomiting, appetite changes, sleep disorders, hot flashes, shortness of breath, sexual and fertility issues, anxiety, and depression among other symptoms.⁵ When symptoms are controlled, quality of life and adherence to cancer treatments (i.e., chemotherapy/biotherapy, radiation, and surgery) and survival are improved.^6

–9

Within the Department of Supportive Oncology at Levine Cancer Institute (an academic hybrid multisite community-based cancer institute), 14% (255/1782) of patients with IO visits (including clinical consults, healing touch, oncology massage, and acupuncture) also visited PM between January 1, 2018 and July 31, 2019. There is limited data on how this compares with other oncology settings, yet it reflects an intentionally blended care approach. IO and PM can achieve synergy when a flexibly defined business plan and innovative solutions to barriers are in place. The purpose of this commentary is to describe 10 structures that foster synergy between IO and PM (Table 1) and five barriers and solutions to integration of the two fields (Table 2). These structures and solutions may be adapted and implemented within other health care organizations.

Table 1.

Ten Structures For Integrative and Palliative Medicine Synergy

Structure	Example(s)	Benefits
1. Collaborative departmental meetings	Weekly grand rounds describe clinical information, challenges, and developments in each field. Weekly research meetings provide interdisciplinary feedback to researchers. Interdisciplinary team meetings to discuss complex clinical cases. Virtual participation is available for off-site attendees.	Diverse perspectives enhance clinical practice and research.
2. Referrals between IO and PM	When appropriate, PM patients are referred to IO for consult and/or integrative modalities (i.e., acupuncture, healing touch, and massage).	Holistic interdisciplinary care is delivered.
2. Referrals between IO and PM	IO patients with complex symptoms are referred to PM. Patients may also be referred from IO and/or PM to additional services across the Department of Supportive Oncology (i.e., nutrition, rehabilitation, senior oncology, survivorship, navigation, and psycho-oncology).	Holistic interdisciplinary care is delivered.
3. Highly trained professionals	Many professionals are trained, certified, or experienced in oncology (e.g., oncology-certified nurses, fellowship-trained integrative medicine physician and advanced practice provider, fellowship-trained hospice and PM physicians, board-certified oncology pharmacist, advanced oncology-certified nurse practitioner, oncology-experienced music therapist, and acupuncturist).	Optimal care is provided.
4. Philanthropy and grants	Scholarships are available for self-pay integrative modalities (i.e., acupuncture and massage).	All patients can benefit from integrative modalities.
5. Collaborative research	Studies involve acupuncture (IO modality) for pain (often treated by PM).	Methodological approaches are enhanced, recruitment is active across multiple clinics, and more patients can participate in high-quality research.
6. Employee exposure to IO and PM	Trainees, clinicians, and administrative support staff are exposed to or cross-trained within IO and PM.	Departmental culture explicitly values the synergistic benefits of IO and PM.
7. Clear leadership within each field	Cohesive services are delivered across the institution by clinical and administrative leaders.	Both fields have designated administrative and clinical leaders. Administrative leaders provide expertise and advocate for services. Clinical leads ensure services are aligned with clinical treatment goals.
8. Comprehensive clinical assessments acknowledge IO and PM treatment approaches	The supportive oncology pharmacist offers medication review and reconciliation (i.e., prescription, nonprescription, herbs, and supplements) to identify drug-related problems. IO and PM clinicians frequently communicate with each other (e.g., “hallway consults”) about the benefits of diverse treatment modalities.	Patients benefit from potentially decreased risk of adverse effects, drug–drug and drug–herb interactions, and polypharmacy that may lower costs and medication burden.
9. Executive leadership support	Leadership advocates for IO and PM through recognition that both improve quality of life and may reduce hospital readmissions, and emergency visits.¹	Nonrevenue-generating services (e.g., music therapy) are maintained.
10. The nation's first outpatient Planetree designation: a health care certification of excellence in person-centered care	Employees are oriented to Planetree principles that value quality of life and holistic care for patients, care partners, and staff.	Formal recognition of person-centered care is consistent with the core tenets of IO and PM.

IO, integrative oncology; PM, palliative medicine.

Table 2.

Five Barriers and Solutions To Incorporate Integrative and Palliative Medicine

Barrier	Solution(s)
1. Patients and medical professionals misunderstand the scope of IO and PM.	Patients and medical professionals are educated through written promotional materials, the cancer resource center, and presentations (e.g., community forums, institution-wide grand rounds, support groups, and community events).
2. Additional health care visits are potentially burdensome due to already demanding health care utilization.	Visits are scheduled adjacent to other medical appointments (e.g., chemotherapy infusion) to maximize efficiency.
3. Services may be difficult to access due to transportation and lack of insurance coverage.	Transportation resources and scholarships for self-pay services are offered.
4. Interventions by initial clinician may mask efficacy of additional interventions.	Clinicians communicate options, use validated symptom assessment, and electronic distress screening to determine patient preference for initial and subsequent interventions. Clinicians and patients practice shared decision making.
5. Difficulty hiring scarce integrative and palliative professionals with specialized training.	Trainees (e.g., medical residents and fellows) rotate through IO and PM to improve exposure, education, and promote interest in the fields. Residency and fellowship program directors, professional organizations, and conferences are contacted during recruitment.

IO, integrative oncology; PM, palliative medicine.

These 10 structures and five innovative solutions to barriers allow IO and PM to converge as collaborative interprofessional teams. The American Society of Clinical Oncology,¹⁰ National Comprehensive Cancer Network,¹¹ and multiple scholars^4,12,13 emphasize the importance of PM within oncology. Likewise, integrative approaches to cancer care are also recognized as beneficial.^14,15 IO and PM can ameliorate the physical and psychologic stressors that negatively impact cancer patients' and survivors' quality of life. Both fields value mental, physical, social, and spiritual well-being beyond cancer treatment. The person-centered principles of IO and PM also provide patient-empowerment opportunities.^16

–19 Through strategic integration of the two fields, holistic multidisciplinary health care is possible.

Footnotes

Acknowledgments

The authors thank Declan Walsh, MD, for his review of the article and members of the Department of Supportive Oncology for their suggestions and support.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received to support this publication.

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