Palliative care services are so crucial to the well-being of patients with cancer that, in 2017, ASCO updated its clinical practice guideline on the integration of palliative care into standard oncology care.1 The updated guideline recommends that all patients with advanced cancer receive dedicated palliative care services early in the disease course, concurrent with active treatment. (See the sidebar on “Essential Components of Palliative Medicine” in the related link below.) For newly diagnosed patients with advanced cancer, the guideline recommends that palliative care begin within 8 weeks of diagnosis.
Jamie H. Von Roenn, MD, FASCO
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD, FASCO. Dr. Von Roenn is ASCO’s Vice President of Education, Science, and Professional Development.
The benefits of introducing early palliative care in the advanced cancer setting have been well established. Patients who receive palliative care in conjunction with standard treatment have a better quality of life, are better able to cope with their diagnosis, and are more likely to discuss their end-of-life care preferences with members of their health-care team.2 However, the COVID-19 pandemic outbreak, still widespread across the United States, and the recommendations from health officials for everyone, especially older adults and those with a serious underlying medical condition including cancer, to socially distance, wear masks, and stay home are upending the normal personal interaction between patients and their palliative care providers.
“We still must continue to provide palliative services to our patients [during COVID-19 pandemic]. We just need to be creative in how we deliver that care.”— Ambereen K. Mehta, MD, MPH
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“The pandemic is challenging the identities of palliative care professionals and causing us to limit our physical contact with patients to reduce their risk of exposure to the coronavirus. However, we still must continue to provide palliative services to our patients. We just need to be creative in how we deliver that care,” said Ambereen K. Mehta, MD, MPH, Assistant Clinical Professor of Palliative Medicine, Department of Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore.
The ASCO Post talked with Dr. Mehta, who recently co-wrote a viewpoint on caring for patients with cancer in the era of COVID-19,3 about how the pandemic is altering the way palliative care is delivered to patients and the importance of maintaining a therapeutic presence to relieve symptoms and provide comfort during this time of medical crisis.
Making Use of Technology
Please talk about how the COVID-19 pandemic is changing the practice of palliative care. Do you think these changes will be permanent?
When the COVID-19 pandemic began in the United States earlier this year, we were not sure how to provide care while keeping our patients, their caregivers, and palliative care professionals safe. The challenges we are facing affect three patient populations: patients with cancer treated on an outpatient basis, inpatients who test positive for COVID-19, and inpatients who test negative for COVID-19.
Despite the challenges of treating patients during this time, we have been able to provide care for all these patients and to be present in their lives, even while sheltering in place, because of the new technology available to us, including telemedicine and videoconferencing. The technology has become an integral part of the way we provide care both in the inpatient and outpatient settings. Using this technology to connect with patients will likely become a permanent strategy after this pandemic is over.
The services we provide patients are very personal, including physical touch and emotional and spiritual support, and we are still able to deliver that care, although our physical presence and touch at bedside are different now because of the personal protective equipment we are required to wear. Although the fundamentals of providing palliative medicine are in place for all patients, some aspects of care, such as conversations about prognosis and goals of care, are more difficult now for patients who test positive for COVID-19 because we don’t know enough about the natural history of the virus to predict with more certainty the trajectory of the disease and what the potential outcome might be.
How we deliver care is also different for these patients. For example, it is generally common to have members of the multidisciplinary palliative care team, including a physician, social worker, and chaplain, be physically present at the patient’s bedside during conversations about goals of care. Now, we are either having these conversations separately at the patient’s bedside or collectively through videoconferencing. Videoconferencing still provides a type of face-to-face communication and allows multiple health-care providers to engage with patients, family members, and caregivers at the same time, which can be challenging in person.
So, we are still able to provide palliative care services, but how we do it has changed.
Balancing Pros and Cons of Telemedicine
What are the challenges of providing palliative care via telemedicine? Are you still able to make a personal connection with patients?
In palliative medicine, physicians are trained to touch patients to offer comfort, and there is something therapeutic about being touched and just sitting close to patients to provide comfort. When I am able to hold a patient’s hand or sit by a patient’s bedside, it makes me feel present in the moment, and I’m able to validate a patient’s emotions and answer questions.
In the clinic, videoconferencing visits are fine, but it is difficult to establish a rapport with patients or their family members or make a connection through a computer screen. At least one randomized study comparing weekly palliative care teleconsultations vs usual in-person palliative care visits showed patients in the telehealth group experienced greater anxiety and distress.4
“Despite the physical distance of telemedicine, there are many advantages to the technology. It breaks down the barrier of accessibility to palliative care….”— Ambereen K. Mehta, MD, MPH
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That said, we are learning how to handle the logistics of the technology and how to use it more effectively. Despite the physical distance of telemedicine, there are many advantages to the technology. It breaks down the barrier of accessibility to palliative care, especially for patients who may have to travel long distances for care or who may have physical limitations or debilitating symptoms from their illness or treatment. The technology also allows me to see into patients’ homes and get a feel for their environment and the people in that world, so it gives me an understanding of patients on a different level.
In the hospital, patients are not allowed visitors during the COVID-19 pandemic. Telehealth allows us to video chat with family members about the patient’s health status and provides an opportunity for patients and family members to maintain a connection while staying apart, record audio or video clips, and even say their goodbyes.
Timing of End-of-Life Conversations
What lessons are you learning from the experience of treating patients during this pandemic that could change how you practice palliative medicine in the future?
It has highlighted for me the difficulty in timing the initiation of goals of care and advance care planning conversations in patients with cancer infected with the coronavirus. We still know so little about this virus and its trajectory in patients with cancer. This is making prognostication about life expectancy, as well as the impact the disease may have on patients’ quality of life, difficult. It is a similar dilemma posed by the advent of advancements in cancer treatment that have allowed patients with incurable cancers to live longer and with a higher quality of life.
Although we still have advance care planning and goals-of-care conversations with these patients early in the course of their incurable cancer, there is greater prognostication uncertainty now. The COVID-19 pandemic has exacerbated the already difficult challenge of balancing hope and realism when discussing prognosis with patients. It has also reinforced the strengths of palliative care medicine in providing patients with complex symptom management, the benefit of multidisciplinary teamwork, and emotional support.
DISCLOSURE: Dr. Mehta reported no conflicts of interest.
1. Ferrell BR, Temel JS, Temin S, et al: Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 35:96-112, 2017.
2. Greer JA, El-Jawahri A, Pirl WF, et al: Randomized trial of early integrated palliative and oncology care. 2016 Palliative and Supportive Care in Oncology Symposium. Abstract 104.
3. Mehta AK, Smith TJ: Palliative care for patients with cancer in the COVID-19 era. JAMA Oncol. May 7, 2020 (early release online).
4. Hoek PD, Schers HJ, Bronkhorst EM, et al: The effect of weekly specialist palliative care teleconsultations in patients with advanced cancer—a randomized clinical trial. BMC Med 15:119, 2017.
Three years ago, ASCO updated its clinical practice guideline on the integration of palliative care into standard oncology care for patients with advanced cancer. The update was based on multiple randomized clinical trials showing better results with concurrent care than with usual oncology care...