Biology healthcare

Please read the two articles listed below. Write a reflection answering the questions. Your reflection should utilize the reading sources for discussion. As always, the reflection should be between 400-500 words at minimum. Please cite any outside sources in addition to the articles used. You do not need to cite the articles provided for you here.

Oncology and Palliative Medicine-Providing Comprehensive Care for Patients with Cancer.pdf

Palliative Care in Special Settings of Cancer.pdf

Actions

1. Define Palliative Care. Define Hospice Care. What is the difference between the two?
2. The composition of the healthcare team and the roles of its members may differ across palliative care settings. Who are professionals that can be involved in this interdisciplinary team? Are there any that surprise you?
3. What is tribalism as discussed in the article?  How would you combat tribalism as a future health care provider?
4. Do you believe Palliative care professionals are affected by tribalism in Oncology? Why or why not?
5. How does a Palliative care team benefit Oncology patients? List 3 reasons on the importance of palliative care integration in Oncology

A Sample Answer For the Assignment: Biology healthcare

Title: Biology healthcare

REVIEWS AND CONTEMPORARY UPDATES Ochsner Journal 17:393–397, 2017 Ó Academic Division of Ochsner Clinic Foundation Oncology and Palliative Medicine: Providing Comprehensive Care for Patients With Cancer Laura Finn, MD,1 Alva Roche Green, MD,2 Sonia Malhotra, MD3,4 1 Division of Hematology and Bone Marrow Transplant, Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA Division of Palliative Medicine, Department of Family Medicine, Mayo Clinic, Jacksonville, FL 3Section of Palliative Medicine, Department of Pulmonary and Critical Care, Ochsner Clinic Foundation, New Orleans, LA 4The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA 2 Background: Despite the evidence for the fundamental need for palliative medicine services in the practice of oncology, integration of these medical specialties remains a clinical challenge. Methods: We reviewed the current literature regarding the practice of palliative medicine in the field of oncology, examining randomized clinical trials of palliative medicine services in advanced cancer, models of palliative medicine delivery, studies of cost effectiveness, and national palliative medicine practice and referral guidelines. In this review, we describe the role of palliative medicine in oncology, including the timing of palliative medicine consultation, models of care delivery, and improvements in patient outcomes. Results: Randomized controlled trials and national guidelines support early referral of patients with cancer to palliative medicine. Palliative medicine has a fundamental role in symptom management, distress relief, family and caregiver support, and advance care planning. Integration of palliative medicine in oncology improves patient outcomes and decreases healthcare costs. Early involvement of palliative medicine after the cancer diagnosis is supported by national guidelines, but barriers include variable referral patterns among oncologists and the need for an expanded palliative medicine workforce. Conclusion: Palliative medicine has a wide-ranging role in the spectrum of comprehensive cancer care—from patient diagnosis to survivorship. The entire multidisciplinary care team has a role in providing palliative care in inpatient and outpatient settings. An effective palliative medicine and oncology collaboration improves patient care and quality of life, has broad research and guideline support, and is cost effective. Keywords: Cancer pain, cost-benefit analysis, medical oncology, palliative medicine, surgical oncology Address correspondence to Laura Finn, MD, Division of Hematology and Bone Marrow Transplant, Department of Internal Medicine, Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121. Tel: (504) 842-3910. Email: [email protected] INTRODUCTION Oncologists are tasked with the care of complex patients in a rapidly evolving field of new therapies through which patient survival has been prolonged. These changes to the cancer trajectory have augmented patients’ need for symptom control and supportive care because patient and caregiver distress may be challenging and prolonged. In the evolving field of oncology, palliative medicine has a growing and important role in managing sources of patient distress and improving patient quality of life (QOL). In this review, we discuss the role of palliative medicine in the practice of oncology, the delivery of palliative medicine and barriers to delivery, the cost effectiveness of palliative medicine, and national guidelines and society recommendations for integrating palliative medicine in oncology. THE ROLE OF PALLIATIVE MEDICINE Palliative medicine is the specialized care of people living with serious illness that focuses on alleviating the burden of Volume 17, Number 4, Winter 2017 symptoms and improving QOL.1 Palliative medicine is appropriate for patients of any age and at any stage of serious illness. It is ideally provided concurrently with curative and life-prolonging treatments. Palliative medicine teams work alongside a patient’s team of specialists to provide symptom and communication expertise, emotional support, assistance with medical decision making, and assistance with end-of-life care and bereavement support when appropriate. Oncologists and primary care physicians provide primary palliative care for initial symptom control, including management of pain and non–pain symptoms of the cancer diagnosis, cancer treatment including stem cell transplants, and cancer survivorship. The approach to primary symptom therapy involves the entire oncology care team with the involvement of additional specialty services such as psychiatry, radiation oncology, and surgery as needed. Secondary palliative care is provided by teams of palliative medicine specialists who build upon the care already 393 Oncology and Palliative Medicine provided during primary palliative services.2,3 Core palliative medicine teams generally consist of physicians, nurses, social workers, and chaplains. Other providers such as psychologists, pharmacists, child life specialists, and music and art therapists are often a part of the multidisciplinary palliative medicine team. Secondary palliative care can facilitate the treatment of challenging symptoms of cancer, including refractory or atypical pain, cancer fatigue, and anorexia. The addition of secondary palliative care enhances the multidisciplinary team and addresses the patient’s needs beyond symptom management: psychosocial needs, caregiver stewardship, and advance care planning. Hannon et al reported in a qualitative study that patients discern distinct roles between their oncologist who provides cancer therapy and their palliative medicine providers who provide symptom control and emotional support.4 A study by Dow et al also showed that patients with cancer may prefer to discuss end-of-life issues with a physician other than their oncologist.5 Evidence shows that early introduction to palliative medicine improves QOL for patients with cancer. In the landmark study by Temel et al, patients with metastatic non– small cell lung cancer were randomized into 2 groups: standard oncology care vs standard oncology care with the integration of outpatient palliative medicine consultation and follow-up visits.6 The group randomized to palliative medicine had improved QOL, anxiety screening, and depression screening scores. Additionally, patients in the palliative medicine group had a lower percentage of deaths in the hospital, less aggressive end-of-life care, and higher rates of resuscitation status preference documentation. Interestingly, improved median survival was also noted in the group receiving palliative care (11.6 vs 8.9 months).6 A metaanalysis of randomized controlled trials in palliative care also showed an association between palliative care intervention and improved patient QOL and decreased symptom burden.7 Caregiver outcomes were variable but consistently showed improvement in caregiver satisfaction. Patient and family support is essential to the field of palliative medicine. Patients and families often have higher rates of satisfaction with their medical care and the quality of communication and support when palliative medicine teams are involved.8 Palliative medicine teams also help patients and families as they transition to end of life and often assist with bereavement support. Early palliative medicine involvement can help families feel less angry and less in denial about the anticipated death of their loved one.9 DELIVERY OF PALLIATIVE MEDICINE Palliative medicine can be provided in a variety of settings, including inpatient hospital consultation, dedicated palliative medicine units, hospital units, outpatient clinics, assisted living and long-term care facilities, and even homebased care. The most familiar model of palliative medicine delivery is inpatient-based services that may involve a single practitioner, consultant palliative medicine team, or even a palliative medicine hospital unit.10 Inpatient palliative medicine should be available for specialty consultation throughout the entire hospital setting—from the emergency department to the intensive care unit. Outpatient oncology access to palliative medicine is a priority as the majority of oncology care is ambulatory. 394 However, fewer than half of the nation’s palliative medicine programs have outpatient services because of challenges in implementation, largely attributable to a palliative medicine workforce shortage.11,12 Early access to outpatient palliative medicine facilitates longitudinal care throughout the patient’s cancer trajectory and improves the transition of care through the spectrum of healthcare settings.13 A single visit with a palliative medicine provider will not fully address the needs of any patient. Establishing palliative medicine clinics in ambulatory oncology practices provides the advantages of increasing access to higher volumes of patients in need, facilitating early referral, and improving communication between the oncologist and palliative medicine team.14 Project ENABLE (Educate, Nurture, Advise, Before Life Ends) showed that palliative medicine can be successfully implemented in a variety of oncology practice models, including cancer centers, private practices, and rural clinics using advanced practice practitioners and via a variety of patient encounters including individual and group meetings. Project ENABLE also showed that palliative medicine can be implemented at the time of advanced cancer diagnosis and that the telephone is a feasible method of intervention.15 The randomized controlled trial ENABLE II further tested the telephone model of intervention and reported an improvement in patient QOL.16 Patients had a lower risk of death in the year after trial enrollment (hazard ratio 0.67, 95% confidence interval 0.496-0.906, P¼0.009) and had increased median survival compared to controls at 14 vs 8.5 months (P¼0.14). When a similar intervention was provided for caregivers of patients with advanced cancer in ENABLE III, caregivers in the intervention group had significantly lower depression scores and stress burden, further supporting early palliative medicine consultations in oncology.17 BARRIERS TO PALLIATIVE MEDICINE DELIVERY One barrier to palliative medicine referrals is the common misperception that palliative care is only associated with end of life.18 However, patients accept palliative medicine intervention without a loss of hope; the ENABLE and ENABLE II studies showed decreased depression in patients who received palliative care, providing evidence that palliative medicine consultations should not be postponed until failure of therapy, symptom crises, or end of life.15,16 One simple yet apparently effective measure for divesting the stigma of palliative care as end-of-life care rather than an additional form of cancer therapy is to add the term supportive care to the name of the palliative medicine team.19 Identifying palliative medicine teams as Palliative Medicine and Supportive Care helps bridge some of the barriers oncologists have in referring patients to palliative medicine services.20-24 The National Comprehensive Cancer Network criteria for patient consultation with palliative medicine include poor pain control, multiple allergies to pain medications, refractory non–pain symptoms, severe comorbidities, and inability to fulfill advance care planning.25 Referrals in practice are usually physician initiated, creating significant variability in patterns of palliative medicine involvement despite the availability of referral guidelines. Clinical symptom and distress screening to trigger palliative medicine consultations by predefined criteria has the potential to improve Ochsner Journal Finn, L early referrals.26-28 Automated referral based on patient symptoms or distress screening scores has been studied in randomized clinical trials and is recommended.6,16,29,30 However, automated referrals are not feasible in most oncology practices because of the palliative medicine workforce deficit. Institutions and private practices need to develop practical pathways for automated referral to secondary palliative care in addition to enhancing the quality of primary palliative care services available. COST EFFECTIVENESS OF PALLIATIVE MEDICINE Healthcare costs and utilization for patients with cancer, especially advanced cancer, and end-of-life care are significant. A study published in 2013 reported a median survival of 3.4-4.7 months for patients with cancer after an unexpected hospital admission, with 73.5%-74.8% of patients deceased by 1 year.31 A study by Adelson et al showed that 30-day readmission rates decrease significantly after standardized palliative medicine consultations.28 Other studies report that direct hospital costs decreased by 14%-32% when palliative medicine consultation was provided within 2 days of admission.32,33 Palliative care consults provided within 1-10 days of admission provide a significant cost savings.33-35 Consults provided within 6 days of admission provided a significant direct cost savings of approximately 14%.33 Another study suggests that patients on Medicaid who receive an early palliative medicine consultation are more likely to receive care outside of the intensive care unit, are less likely to be hospitalized repeatedly, and enroll in hospice earlier.36 Referral to outpatient palliative care within 3 months of the end of life also decreases hospital admission, decreases costs, increases hospice utilization, and improves patient QOL.37,38 The Centers for Medicare and Medicaid Services provides separate payment for advance care planning discussions, a benefit that should promote palliative medicine services.39 Appropriate use of palliative medicine services can yield institutional annual savings of nearly $2 million by decreasing patient length of stay and daily hospital costs.40,41 treatment.43 Evidence is provided by studies, including randomized controlled trials, that palliative medicine improves pain and symptom control, improves caregiver satisfaction with care, and reduces healthcare costs.43 CONCLUSION Palliative medicine has an extensive role in oncology beginning when patients are diagnosed, continuing through treatments, and concluding with survivorship or end-of-life care. Oncologists are primary palliative care providers who are responsible for maximizing patient QOL by requesting palliative medicine consultations at the most beneficial time in the cancer trajectory to avoid and relieve patient distress. Patients with any serious illness deserve exceptional symptom management and supportive care. All patients deserve the setting and opportunity to consider and communicate their wishes for advance care planning. Oncologists and palliative medicine providers are intimate colleagues in all of these tasks. Effective collaboration with palliative medicine improves patient outcomes, is cost effective, and has the broad support of clinical research and treatment guidelines. ACKNOWLEDGMENTS The authors have no financial or proprietary interest in the subject matter of this article. REFERENCES 1. 2. 3. 4. 5. SOCIETY RECOMMENDATIONS The evidence for a synchronized effort between oncology and palliative medicine is compelling, leading to guidelines statements from prominent oncology and palliative medicine societies. In February 2017, the American Society of Clinical Oncology (ASCO) updated its clinical practice guideline for the integration of palliative medicine into oncology to recommend that all patients with advanced cancer receive palliative medicine services within 8 weeks of their diagnosis and concurrent with active treatment in both the inpatient and outpatient settings.42 Referring patients to multidisciplinary palliative medicine services is optimal. ASCO defines patients with advanced cancer as those with metastasis, late-stage cancer, and/or a prognosis of 24 months or less.42 As part of the Choosing Wisely initiative of the American Board of Internal Medicine, the American Academy of Hospice and Palliative Medicine calls for no delay in palliative care for patients with serious illness who are in any form of distress because they are receiving active Volume 17, Number 4, Winter 2017 6. 7. 8. 9. Summary Data. Center to Advance Palliative Care and National Palliative Care Research Center. National Palliative Care Registry. https://registry.capc.org/metrics-resources/ summary-data/. Accessed August 15, 2016. Hui D. Definition of supportive care: does the semantic matter? Curr Opin Oncol. 2014 Jul;26(4):372-379. doi: 10.1097/CCO. 0000000000000086. Hui D, Bruera E. Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol. 2016 Mar;13(3):159-171. doi: 10. 1038/nrclinonc.2015.201. Hannon B, Swami N, Pope A, et al. Early palliative care and its role in oncology: a qualitative study. Oncologist. 2016 Jul 22. [Epub ahead of print]. Dow LA, Matsuyama RK, Ramakrishnan V, et al. Paradoxes in advance care planning: the complex relationship of oncology patients, their physicians, and advance medical directives. J Clin Oncol. 2010 Jan 10;28(2):299-304. doi: 10.1200/JCO.2009.24. 6397. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-742. doi: 10.1056/ NEJMoa1000678. Kavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes: a systematic review and meta-analysis. JAMA. 2016 Nov 22; 316(20):2104-2114. doi: 10.1001/jama.2016.16840. Holland JM, Keene JR, Kirkendall A, Luna N. Family evaluation of hospice care: examining direct and indirect associations with overall satisfaction and caregiver confidence. Palliat Support Care. 2015 Aug;13(4):901-908. doi: 10.1017/ S1478951514000595. Kim SH, Hwang IC, Ko KD, et al. Association between the emotional status of family caregivers and length of stay in a palliative care unit: a retrospective study. Palliat Support Care. 2015 Dec;13(6):1695-1700. doi: 10.1017/S1478951515000619. 395 Oncology and Palliative Medicine 10. Bruera E, Hui D. Conceptual models for integrating palliative care at cancer centers. J Palliat Med. 2012 Nov;15(11): 1261-1269. doi: 10.1089/jpm.2012.0147. 11. Davis MP, Strasser F, Cherny N. How well is palliative care integrated into cancer care? A MASCC, ESMO, and EAPC project. Support Care Cancer. 2015 Sep;23(9):2677-2685. doi: 10. 1007/s00520-015-2630-z. 12. Davis MP, Strasser F, Cherny N, Levan N. MASCC/ESMO/EAPC survey of palliative programs. Support Care Cancer. 2015 Jul; 23(7):1951-1968. doi: 10.1007/s00520-014-2543-2. 13. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003 Apr; 51(4):549-555. 14. Muir JC, Daly F, Davis MS, et al. Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manage. 2010 Jul;40(1):126-135. doi: 10.1016/j. jpainsymman.2009.12.017. 15. Bakitas M, Stevens M, Ahles T, et al. Project ENABLE: a palliative care demonstration project for advanced cancer patients in three settings. J Palliat Med. 2004 Apr;7(2):363-372. 16. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009 Aug 19;302(7):741-749. doi: 10.1001/jama.2009. 1198. 17. Dionne-Odom JN, Azuero A, Lyons KD, et al. Benefits of early versus delayed palliative care to informal family caregivers of patients with advanced cancer: outcomes from the ENABLE III randomized controlled trial. J Clin Oncol. 2015 May 1;33(13): 1446-1452. doi: 10.1200/JCO.2014.58.7824. 18. Cherny NI. Stigma associated with ‘‘palliative care’’: getting around it or getting over it. Cancer. 2009 May 1;115(9): 1808-1812. doi: 10.1002/cncr.24212. 19. Roeland E, Ku G. Spanning the canyon between stem cell transplantation and palliative care. Hematology Am Soc Hematol Educ Program. 2015;2015:484-489. doi: 10.1182/ asheducation-2015.1.484. 20. Dalal S, Palla S, Hui D, et al. Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center. Oncologist. 2011;16(1):105-111. doi: 10.1634/theoncologist.2010-0161. 21. Fadul N, Elsayem A, Palmer JL, et al. Supportive versus palliative care: what’s in a name?: a survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2009 May 1;115(9):2013-2021. doi: 10.1002/cncr.24206. 22. Hui D, Park M, Liu D, Reddy A, Dalal S, Bruera E. Attitudes and beliefs toward supportive and palliative care referral among hematologic and solid tumor oncology specialists. Oncologist. 2015 Nov;20(11):1326-1332. doi: 10.1634/theoncologist. 2015-0240. 23. Wentlandt K, Krzyzanowska MK, Swami N, Rodin GM, Le LW, Zimmermann C. Referral practices of oncologists to specialized palliative care. J Clin Oncol. 2012 Dec 10;30(35):4380-4386. doi: 10.1200/JCO.2012.44.0248. 24. Maciasz RM, Arnold RM, Chu E, et al. Does it matter what you call it? A randomized trial of language used to describe palliative care services. Support Care Cancer. 2013 Dec;21(12): 3411-3419. doi: 10.1007/s00520-013-1919-z. 25. Levy MH, Adolph MD, Back A, et al. Palliative care. J Natl Compr Canc Netw. 2012 Oct 1;10(10):1284-1309. 26. Lee SJ, Katona LJ, De Bono SE, Lewis KL. Routine screening for psychological distress on an Australian inpatient haematology and oncology ward: impact on use of psychosocial services. Med J Aust. 2010 Sep 6;193(5 Suppl):S74-S78. 396 27. Wagner LI, Schink J, Bass M, et al. Bringing PROMIS to practice: brief and precise symptom screening in ambulatory cancer care. Cancer. 2015 Mar 15;121(6):927-934. doi: 10.1002/cncr. 29104. 28. Adelson K, Paris J, Horton JR, et al. Standardized criteria for palliative care consultation on a solid tumor oncology service reduces downstream health care use. J Oncol Pract. 2017 May; 13(5):e431-e440. doi: 10.1200/JOP.2016.016808. 29. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a clusterrandomised controlled trial. Lancet. 2014 May 17;383(9930): 1721-1730. doi: 10.1016/S0140-6736(13)62416-2. 30. Bakitas MA, Tosteson TD, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015 May 1;33(13):1438-1445. doi: 10.1200/JCO.2014.58. 6362. 31. Rocque GB, Barnett AE, Illig LC, et al. Inpatient hospitalization of oncology patients: are we missing an opportunity for endof-life care? J Oncol Pract. 2013 Jan;9(1):51-54. doi: 10.1200/JOP. 2012.000698. 32. May P, Garrido MM, Cassel JB, et al. Palliative care teams’ costsaving effect is larger for cancer patients with higher numbers of comorbidities. Health Aff (Millwood). 2016 Jan;35(1):44-53. doi: 10.1377/hlthaff.2015.0752. 33. May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015 Sep 1;33(25):2745-2752. doi: 10.1200/ JCO.2014.60.2334. 34. Starks H, Wang S, Farber S, Owens DA, Curtis JR. Cost savings vary by length of stay for inpatients receiving palliative care consultation services. J Palliat Med. 2013 Oct;16(10):1215-1220. doi: 10.1089/jpm.2013.0163. 35. McCarthy IM, Robinson C, Huq S, Philastre M, Fine RL. Cost savings from palliative care teams and guidance for a financially viable palliative care program. Health Serv Res. 2015 Feb;50(1):217-236. doi: 10.1111/1475-6773.12203. 36. Morrison RS, Dietrich J, Ladwig S, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011 Mar;30(3):454-463. doi: 10.1377/hlthaff.2010.0929. 37. Blackhall LJ, Read P, Stukenborg G, et al. CARE track for advanced cancer: impact and timing of an outpatient palliative care clinic. J Palliat Med. 2016 Jan;19(1):57-63. doi: 10.1089/jpm. 2015.0272. 38. Scibetta C, Kerr K, Mcguire J, Rabow MW. The costs of waiting: implications of the timing of palliative care consultation among a cohort of decedents at a comprehensive cancer center. J Palliat Med. 2016 Jan;19(1):69-75. doi: 10.1089/jpm. 2015.0119. 39. Centers for Medicare and Medicaid Services. Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule for Calendar Year 2017. https://www. cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/ 2016-Fact-sheets-items/2016-11-02.html. Accessed June 13, 2017. 40. Cowan JD. Hospital charges for a community inpatient palliative care program. Am J Hosp Palliat Care. 2004 May-Jun; 21(3):177-190. 41. Ciemins EL, Blum L, Nunley M, Lasher A, Newman JM. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J Palliat Med. 2007 Dec;10(6):1347-1355. Ochsner Journal Finn, L 42. 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. 2017 Jan;35(1):96-112. 43. Fischberg D, Bull J, Casarett D, et al. Five things physicians and patients should question in hospice and palliative medicine. J Pain Symptom Manage. 2013 Mar;45(3):595-605. doi: 10.1016/j. jpainsymman.2012.12.002. This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, and Practice-Based Learning and Improvement. Volume 17, Number 4, Winter 2017 397 Special Series: Palliative Care EDITORIAL Palliative Care in Special Settings of Cancer Care Charles F. von Gunten OhioHealth Kobacker House, Columbus, OH ASSOCIATED CONTENT See accompanying articles on pages e703, e712, e721, and e729 DOI: https://doi.org/10.1200/JOP. 2017.025551; published online ahead of print at jop.ascopubs.org on August 16, 2017. There are strong data showing that palliative care, when combined with standard cancer care, yields better outcomes than standard cancer care alone.1 Now the challenge is to make this improvement practically available in routine care—even in transplantation.2 This issue of Journal of Oncology Practice (JOP) highlights this development with some individual reports. I want to put that development in the context of the broad range of experimentation now occurring in the effort to overcome this challenge. I rely not only on published reports but also on my personal knowledge as well as my own perceptions as a medical oncologist who has worked toward this goal in several institutions. Tribalism Tribalism is a bold word that summarizes the behavior of people who identify themselves as part of a group. Oncology as a whole is a tribe with its own customs, language, and conventions. Within oncology, surgical, radiation, medical, gynecologic, malignanthematologic,transplantation,and pediatric fields are distinct tribes with distinctive rites and rituals of usual behavior that are carried out in special settings. Successful integration of palliative care requires a keen and unabashed recognition of this. Most important, in my experience, is language. The prolonged training of oncologists of any stripe gives them a unique language. When someone in palliative care does not know how to “speak cancer,” he or she is frequently shunned, denigrated, and not brought into the treatment team. It is not different from visiting Paris and not speaking Copyright © 2017 by American Society of Clinical Oncology French—you do not feel welcome. Although those without oncology backgrounds can provide excellent palliative care for patients with cancer, if they do not understand the language and/or work to learn it, the wonderful alchemy of interdisciplinary teamwork will not happen. Consequently, in my judgment, these collaborations work best when at least one of the palliative medicine physicians has a cancer background. Second best is a palliative medicine clinician who, like a visitor to France, learns the language and customs first and approaches the situation with cultural humility. I have seen too many promising programs fall apart because the family or internal medicine physicians staffing the palliative medicine service or the nurse practitioners who have not worked in cancer are labeled as nihilists or as people who do not get it, and the service dies. All it takes is one of them to say, “The patient had a few rounds of chemotherapy,” or, about the patient with a positive response to chemotherapy for lymphoma admitted for neutropenic fever, “I think it’s time for hospice now,” and the ears and minds of oncologists close to the idea that palliative care has anything to offer modern oncology or its patients. In each of the special settings where there is so much promise for palliative care (transplantation, pediatrics, and singlespecialty programs like sarcoma or lung cancer), the palliative care teamneeds to have a deep understanding of the overall cancer medicine into which the palliative care fits, rather than being an add-on like a caboose to a train—an appendage that is not integral to the work. The contribution of Wang et al3 Volume 13 / Issue 9 / September 2017 n jop.ascopubs.org Downloaded from ascopubs.org by 72.131.202.35 on October 7, 2020 from 072.131.202.035 Copyright © 2020 American Society of Clinical Oncology. All rights reserved. 597 von Gunten accompanying this editorial illustrates this in a setting where clinical palliative care is a routine part of the transplantation program in both the inpatient and outpatient settings. The Business of Oncology One of the tribal norms common to all oncology is that the field is organized around the oncologists and the business models that guide the practice of cancer medicine. If it were patientand family-centered, patients would not have to go to separate offices with separate staffs in sometimes disparate locations. Outside of dedicated cancer centers in academic settings, it is rare that surgical, radiation, and medical components all work in the same physical location, where the patient can be in an examination room and have all the disciplines see him or her there. Most cancer care is provided by private practice oncologists with their own businesses, their own offices, and their own corporate approaches. It is easier to handle billing and manage a practice this way—in fact, revenue is maximized. If palliative care is operationalized using the same patterns, it fragments the care still further by adding a fourth place to go, a fourth group of health care providers, another cost center, and another management structure for assuring preauthorizations, registration, and billing. The consequence is a high noshow rate approaching 50% to 70% in many places. People sick enough to need palliative care combined with their cancer care do not have the time or energy for yet one more place to go. Even worse, the real-time collaboration necessary for the palliative care plan to complement and support the overall cancer treatment plan does not occur. Consequently, these models frequently lead to the writing of opioid prescriptions for troublesome patients who make their oncologists nervous or irritable—a dumping ground. The promise of interdisciplinary palliative care is lost. If, in contrast, the palliative care team is embedded in the cancer care, as described by Einstein et al4 in JOP, they see patients in the offices of the surgical, radiation, or medical oncologists. This enables joint visits when needed and strengthens the collaboration, teaching, and patient centeredness of the care. Patients and families love it. Practice administrators hate it because the scheduling software, usual patterns for allocating rooms and space, and culture (meaning the way things are done around here) are not designed for this way of organizing care. However, the same engine that ensures reauthorizations for chemotherapy or radiation therapy or surgery can also work for opioids or other drugs or interventions—it just represents a change. Most importantly, there needs to be enough space so that the oncologist can 598 move on while palliative care may tie up a room for 30 to 60 minutes for extensive teaching, counseling, or planning. Getting the Right People Palliative care teams are composed of physicians, nurses (often nurse practitioners), social workers, chaplains, and pharmacists. The reason for this is that palliative care addresses physical (eg, pain and nausea), emotional (eg, fear and anger), practical (eg, how work, home, money, and family are affected and what needs to change), and spiritual aspects of cancer (eg, “Why is this happening to me?”). For palliative care teams to be effective in the outpatient setting of cancer care, team members need to work well not just with one another but also with everyone in the oncology office: front desk staff, infusion center staff, medical assistants, and so on. In short, they need to fit. Selection of the team members should involve everyone who will work with them, and after qualifications are established, the key attribute for hiring is: “Do they fit with us and our culture?” The accompanying contributions of Hay et al5 and Buckey de Meritens et al6 in JOP illustrate that the oncologists are not the problem—they understand that palliative care is useful for both symptom control and support throughout the course of illness. However, the right people are needed on the palliative care team—those who can work well within the oncology tribe, respecting the tribal members and rituals while adding a unique component that research has demonstrated adds both quality and length of life. Author’s Disclosures of Potential Conflicts of Interest Disclosures provided by the authors are available with this article at jop.ascopubs.org. Corresponding author: Charles F. von Gunten, MD, PhD, OhioHealth Kobacker House, 800 McConnell Dr, Columbus, OH 43214; e-mail: charles.vongunten@ ohiohealth.com. References 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. El-Jawahri A, LeBlanc T, VanDusen H, et al: Effect of inpatient palliative care on quality of life 2 weeks after hematopoietic stem cell transplantation: A randomized clinical trial. JAMA 316:2094-2103, 2016 3. Wang W, Ma JD, Nelson SH, et al: Advance care planning and palliative care integration for patients undergoing hematopoietic stem-cell transplantation. J Oncol Pract 13:e721-e728, 2017 4. Einstein DJ, DeSanto-Madeya S, Gregas M, et al: Improving end-of-life care: Palliative care embedded in an oncology clinic specializing in targeted and immunebased therapies. J Oncol Pract 13:e729-e737, 2017 5. Hay CM, Lefkowits C, Crowley-Matoka M, et al: Strategies for introducing outpatient specialty palliative care in gynecologic oncology. J Oncol Pract 13:e712-e720, 2017 6. Buckey de Meritens A, Margolis B, Blinderman C, et al: Practice patterns, attitudes, and barriers to palliative care consultation by gynecologic oncologists. J Oncol Pract 13:e703-e711, 2017 Volume 13 / Issue 9 / September 2017 n Journal of Oncology Practice Copyright © 2017 by American Society of Clinical Oncology Downloaded from ascopubs.org by 72.131.202.35 on October 7, 2020 from 072.131.202.035 Copyright © 2020 American Society of Clinical Oncology. All rights reserved. Editorial AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Palliative Care in Special Settings of Cancer Care The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I 5 Immediate Family Member, Inst 5 My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/journal/jop/site/misc/ifc.xhtml. Charles F. von Gunten Honoraria: Salix, Otsuka, AstraZeneca Consulting or Advisory Role: AstraZeneca Speakers’ Bureau: Salix Expert Testimony: Finnegan Law Firm representing Wyeth, Salix, Progenics Travel, Accommodations, Expenses: Salix Copyright © 2017 by American Society of Clinical Oncology Volume 13 / Issue 9 / September 2017 n jop.ascopubs.org Downloaded from ascopubs.org by 72.131.202.35 on October 7, 2020 from 072.131.202.035 Copyright © 2020 American Society of Clinical Oncology. All rights reserved.