Palliative Care in 2014

A Conversation With Diane E. Meier, MD

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Diane E. Meier, MD

People in the community now understand that palliative is not a nice-to-have service; it’s a must-have part of the cancer care continuum.

—Diane E. Meier, MD

Palliative care expert Diane E. Meier, MD, is the Director of the Center to Advance Palliative Care (CAPC), a national organization devoted to enhancing the number and quality of palliative care programs across the nation. Under her leadership, the number of palliative care programs in the United States has more than tripled over the past 10 years. The ASCO Post recently spoke with Dr. Meier about the evolving role of palliative care throughout the oncology delivery system.

Major Advances

Palliative care’s integration into standard of care in oncology has, in some ways, been an uphill battle. What are the biggest advances you’ve seen in this field in your career?

The most notable advance has occurred quite recently with the accumulating body of evidence demonstrating that concurrent delivery of palliative care with best practices in cancer care not only improves quality of life for patients and families, it also prolongs life. To the credit of the oncology community, this accumulating body of data is driving change in oncologic delivery and service models. People in the community now understand that palliative is not a nice-to-have service; it’s a must-have part of the cancer care continuum.

The first goal of palliative care is to best serve our patients and families, placing them at the center of our palliative care mission. Naturally, if patients feel better, they are more likely to complete their appropriate cancer treatments. Hence, palliative care extends the patient’s life, and that’s our mission as oncologists. So this important message, backed by data, is now catching on. I think about 87% of [National Cancer Institute]–designated comprehensive cancer centers have integrated high-quality palliative care teams into their delivery model.

Moreover, realizing that palliative care was not restricted to end-of-life care was a true paradigm shift in oncology; as a community we finally embraced the notion of treating the whole person with concurrent palliative care intervention, not just treating the disease. It was a huge step forward in patient care.

Pain Management

Despite growing awareness by the major cancer organizations, undertreated cancer pain is still a serious clinical problem. Where are we in this challenge, and what is the way forward to ensure that all our cancer patients have their pain properly managed?

Appropriate management of pain has seen a couple of major pendulum swings in this country. Twenty years ago there was real fear of prescribing opioids. For one thing, doctors dreaded having their offices raided and being handcuffed by drug enforcement agents and hauled off to jail. Following this overreaction, there was a widespread movement to educate physicians and the public that opioids were the gold standard of pain control and that pain was a bad symptom that needed to be controlled.

However, some people oversold the safety component of opioid analgesics. We then saw some inappropriate use of these drugs by physicians, most of whom were prescribing opioid analgesics for chronic pain as opposed to cancer pain. Unfortunately, during this period, there was a thriving street-drug trade that ultimately led to a series of overdoses and deaths, all of which garnered national attention in the lay press.

As a reaction, the pendulum swung back the other way, leading to tighter restrictions and tougher [U.S. Food and Drug Administration] labeling on opioid analgesics. The challenge for us in health care is to achieve a proper balance, and the key to that balance is ensuring that all of the health-care professions with prescribing privileges, from doctors to physician assistants, are properly educated.

Appallingly, the vast majority of people who prescribe opioid analgesics have had little to no training in the safe and effective use of these drugs. Remarkably, it is not a required component in the medical curricula. Consequently, we are graduating doctors and turning them out into the health-care system without these essential skills. There will never be enough palliative care specialists to manage pain, so we need to make sure that every health-care professional who services our patients is trained in the proper use of pain medications.

Training Initiative

How do we begin a training initiative of that huge scale?

It requires a systematic approach. Because I believe so strongly in this issue, my organization, CAPC, is developing a comprehensive palliative care clinical curriculum aimed at every clinician who cares for people with serious illnesses, with special emphasis on oncologists.

For example, there are 12 different interactive courses on safe and effective opioid prescribing—that can be taken on any mobile device—which is 12 times more than anyone got in medical school residency or fellowship. If one passes these courses and receives a CAPC designation, patients and family members can be confident that that the clinician has a firm knowledge of how to properly prescribe and use opioid analgesics.

Importantly, in the first quarter of 2015, CAPC will become a membership organization, with membership open to health-care organizations including hospitals, hospices, and nursing homes, as well as home care agencies and payers. Once an organization joins us, all the clinical staff of that organization will have full access to CAPC’s expanded training and technical assistance content, including Continuing Education Units and Continuing Medical Education.

We’ll offer a number of value-added courses such as integrating palliative care into the nursing home setting. These courses also help managers, whether they’re clinicians or administrators, understand the components of a high-quality palliative care delivery system. For instance, how can you get paid and measure quality and make sure your staff is adequately trained? The courses offer a full spectrum of valuable and actionable knowledge.

Closing Thoughts

Any last thoughts on this field that you’ve dedicated your career to?

Palliative care is about meeting the patient and the family and understanding where they are in their particular clinical situation. It’s about understanding patients’ hopes and fears and what matters most to them, and then using the power that our training has given us as doctors to help those people achieve their goals.

Each person battling a serious illness has unique priorities, and it is our job to mobilize the health-care system in the service of each patient and family. The patient is not just another cog in the system, and we must remember that the sole reason for palliative care is to rekindle the roots of the healing profession. It’s about the patient as a person.

The cost element, which is important in overall health care, is not what palliative care is all about. However, there are analyses demonstrating that palliative care intervention prevents many unnecessary emergency room visits, which of course saves the system money.

There are other examples where palliative care saves money by addressing symptoms before they become emergencies. The cost-saving issues are a side effect of delivering better quality of care, but they are not part of the intended role of palliative care.

That’s an important distinction because, in palliative care, we often advocate for very expensive therapies if we think they are beneficial for our patients. Delivering the best care possible is what drives palliative care, no matter how much it costs. It’s all about meeting the needs and goals of the patient in front of us. ■

Disclosure: Dr. Meier reported no potential conflicts of interest.


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