Getting by with a Little Help from Our Friends

Dear Editor:

Following convincing evidence that providing comprehensive palliative care to patients with newly diagnosed advanced lung cancer unequivocally led to better outcomes, in 2012 the American Society of Clinical Oncology (ASCO) recommended this become the standard of care for all oncology practices at the time of diagnosis.^1–4 The greatest challenges were and continue to be two, in particular—(1) convincing medical oncologists that this is a true priority and (2) finding a palliative care provider, given limited availability, particularly in medically underserved communities and in the fee-for-service world of private practice.

We created a strong inpatient palliative medicine service at our community hospital, ⁵ and then set up two small outpatient palliative care clinics: one embedded in our five-physician oncology practice, and the other in a separate hospital-owned outpatient clinic. ⁶ In the oncology practice, the oncologist/palliative care physician worked alone, and in the hospital's outpatient clinic, the physician teamed up with a palliative trained social worker. We were open to all comers, taking referrals from physicians (oncologists or otherwise) as well as self-referrals from patients, and encouraged patients with any appropriate oncologic or nononcologic diagnosis, or simply the frail elderly.

How well were we doing in meeting the ASCO goal of seeing all advanced lung cancer patients within 60 days of diagnosis, we wondered? We retrospectively identified all new stages IIIB and IV lung cancer diagnoses made through our cancer registry at the hospital for the year 2018, and then reviewed their charts, with particular attention to date of diagnosis, whether palliative care consultation had ever transpired, and the date of consultation. (Other measures included where this had taken place, who the referring provider was, if a Physician Orders for Life-Sustaining Treatment (POLST) had been completed, if there was a transition to hospice care, and place of death.) Some of the findings are summarized in the accompanying Table 1.

The disappointing discovery was that, of the 29 patients diagnosed with advanced lung cancer that year, not one of them had a palliative medicine consultation through either clinic—even though we had nested one of the clinics in the oncology practice, and all the full-time practicing oncologists were well aware of it, and the other palliative care clinic, independent of the large oncology practice, was available for the solo oncologist practitioner to use. There was a steady stream of referrals, but no lung cancer patients had appeared. A mighty failure.

And yet, as we reviewed all 29 charts for that year, we discovered that one after another of the lung cancer patients did indeed have a palliative care consultation—in fact, a startling 83%—but that these had all taken place as inpatients. Furthermore, not only were most of the patients seen within 60 days of diagnosis (75% of the entire group), but also 58% were seen within the first week after the diagnosis. Were our eager and enlightened oncologists jumping on the opportunity to get palliative care involved as early as possible, just days after the diagnosis was made?

Not exactly. Of all the referring physicians, just 25% were medical oncologists, and 8% were radiation oncologists. The major referral source was the hospitalists, who had engineered 58% of the referrals. They were, of course, oblivious with regard to ASCO recommendations; they simply wanted help in getting these patients' symptoms managed, goals of care established, and code status addressed.

We realized that most of our new advanced lung cancer patients had been hospitalized with symptoms first, and then the diagnosis was made in the hospital—hence, a captive audience. But more importantly, our inpatient palliative care team had developed such strong relationships with the hospitalists over the preceding five or so years that the hospitalists had learned to request a palliative care consultation almost automatically on virtually any patient with advanced malignancy, and usually within days after admission; in some cases, the referral to palliative care was made before the actual diagnosis of cancer was established. The key was ongoing education and support of the hospitalists, who had learned from firsthand experience that the palliative care team was not just for end-of-life care and hospice discussions, but also for any of their complicated patients, particularly with serious diagnoses, and that the team made their lives easier. More often than not, the team got pain under control, put the patient-controlled analgesia (PCA) in place if needed, provided the supportive hour or two at the bedside that was simply not possible for the hospitalist, established a sensible code status, completed a POLST, and aggressively helped with realistic discharge plans. And irrespective of what was or was not taken care of at that first evaluation, the palliative team began a relationship with patient and family that would carry over to the next admission, an all too common occurrence in the advanced cancer patient population.

Who would have guessed the inpatient palliative care team's strong and steady work with our hospitalist colleagues would be so instrumental in meeting a tremendously important and otherwise elusive outpatient ASCO guideline goal? Through skillful nurturing, our hospitalist colleagues became front line palliative champions.