The perspectives of oncology healthcare providers on the role of palliative care in a comprehensive cancer center

This is the only study in the U.S. that surveyed a variety of oncology providers at a single CCC about attitudes and barriers regarding PC utilization in both inpatient and outpatient settings. The majority of respondents were interested in increasing PC services for their patients. We found differences between the role of outpatient and inpatient PC. Respondents reported that complex pain, complex symptoms, and advanced cancer patients were important services provided by PC in the outpatient setting, and in contrast respondents valued inpatient PC management for goals of care discussions and transition to hospice. The reasons for this significant difference between outpatient and inpatient needs has not been previously identified. The reason for this may be related to the acuity of issues found in the different settings, and that perhaps oncologists are more comfortable and/or able to address goals of care and hospice transition in the outpatient clinic. Additionally, we found that 3 in 4 providers preferred an oncology-focused PC team and felt having the same PC clinicians for outpatient and inpatient was important for continuity of care. The only other similar survey of a variety of oncology healthcare providers gathered opinions about the benefit of early specialist PC at a tertiary cancer center in India [11]. This study reported that oncologists and oncology nurses agreed that early integration of PC in cancer care improves symptom control, end-of-life care, and healthcare-related communication. Compared to nurses, oncologists indicated a greater appreciation for PC interventions in end-of-life care management but not for symptom control or communication.

Surveys of physicians have revealed largely positive attitudes about PC and belief that PC is under-utilized [12,13,14]. An integrative review of nurses’ attitudes revealed positive views of PC but also a lack of knowledge about PC [15]. One survey of nurses at a U.S. CCC found that oncology nurses had, on average, a strongly positive attitude toward caring for dying patients, though nurses with less experience tended to be less supportive of PC [16]. Our study provides additional evidence that both oncologists and nurses believe that PC interventions improve end-of-life care and symptom management. Contrary to the study by Salins et al., which found a stronger preference for end-of-life PC intervention among oncologists relative to nurses, our study did not find significant differences between opinions of different types of healthcare providers.

The 2017 practice guidelines established by the ASCO include the recommendation that PC for patients with advanced cancer should be delivered through interdisciplinary care teams with consultation available in both outpatient and inpatient settings [5]. While there is evidence supporting the efficacy of such integrated models, there is no published research examining the precise roles of the inpatient and outpatient components of these models and their utilization by oncology health care providers. To date, surveys of healthcare providers have not compared the two settings. Our study revealed some divergence in opinions about the roles of outpatient versus inpatient PC, barriers to those services, and satisfaction. It should be noted that at the time of the survey, the outpatient PC was a cancer focused team while the inpatient PC team was not, which may account for some of the differences found.

Several previous studies have surveyed oncology providers about reasons for PC referral [11, 13, 17,18,19,20,21,22]. These reasons, which include pain and symptom management, end-of-life care, depression/anxiety, and exhaustion of curative treatment options, suggest desirable roles for PC in the context of oncology. These studies show that PC is valued for pain and symptom relief in both inpatient and outpatient settings. Symptom management was identified as the most important role for PC at the cancer center, which is consistent with results from previous surveys [14, 20, 22]. Of note, only half of respondents reported psych-spiritual support as an important role for the PC service. This could be related to clinicians believing other services were also available to address this need, such as social work or psychiatry, and/or a lack of understanding of the holistic nature of PC. Assisting with goals of care and transition to hospice were noted to be significantly more important for inpatient PC than for outpatient PC. Respondents specified that they prefer to utilize PC to continue care when no other therapy options remain, yet many also agree that early referral is beneficial for patients. Previous surveys have shown that oncology providers largely agree that cancer patients should receive PC early in the disease course, but actual referral practices often fall short of this goal [14, 23]. This discrepancy may be due to the limited availability of PC services and decisions to reserve PC resources for patients at advanced stages of disease who may be most in need.

Systematic reviews have assessed the barriers to specialist PC access, barriers to integration of oncology and PC and factors influencing referrals to specialist PC [8, 9, 24]. The most-reported barriers are system-related and include limited availability of PC services, poor communication between teams, lack of interdisciplinary communication, and low insurance reimbursement. Limited PC availability has been cited as a major barrier to PC referral in several physician surveys, and also found in this study [12, 13, 18, 25]. Provider-related barriers include gaps in knowledge about PC referral practices, fear of estranging patients and families or of deflating hope, belief in incompatibility with ongoing antitumor treatment, lack of time to address PC needs, and stigma associated with the discipline of PC.

Uncertainty about how and when to refer was provided as an additional barrier to PC referral. Most respondents did agree that an automatic assessment and referral built into the electronic medical record would be helpful. Interestingly, it is concordant with the consensus of a panel of international experts that the model of physician referral augmented by automatic referral is an optimal PC referral structure [26]. This is inconsistent with results from other physician surveys, which have shown that oncologists prefer to actively coordinate care and determine the time of PC referral [17]. Respondents showed a strong preference for a PC team with an oncology focus rather than a team that sees other patients in addition to oncology patients. Additionally, most respondents also felt that care would be improved by having the same PC team see patients in both inpatient and outpatient settings.

This study has limitations. Selection bias is possible, though this risk is tempered by the response rate of 62%, which is high for voluntary electronic surveys among healthcare providers. Data from the current study may reflect the opinions of those healthcare providers with an interest in PC. Of note, a significant proportion of respondents had been working at the CCC for < 5 years. Responses to the survey were limited to a single CCC in the Midwestern United States and therefore cannot be generalized out of that setting. The survey tool itself was not validated and this survey was done prior to the COVID pandemic and the increased utilization of telehealth modalities. Lastly, we did not include aspects of home palliative care, which is an important part of the array of services provide for patients [27].

Additional surveys are needed at CCCs to confirm these findings. Evaluations of general PC versus cancer-focused PC are needed to understand the impact of each approach. Future studies are needed to assess patient and family opinions about the role and accessibility of inpatient and outpatient PC, particularly among underserved or disadvantaged patient populations. Additionally, whereas this study gathered opinions of only oncology providers, future studies are needed to understand the perspectives of PC providers. We also need more data about innovative models of integrated PC that improve integration and availability.

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