Expert: Recognizing the Importance of Early Palliative Care Referrals Is Essential to Patient Care

In an interview with Pharmacy Times at the American Society of Clinical Oncology (ASCO) 2022 Annual Meeting, Ajeet Gajra, MD, MBBS, FACP, discussed research that found that utilizing an augmented intelligence-based system can improve the timeliness of referrals to palliative care and hospice services in community oncology environments.

Can you discuss the importance of timely referrals to palliative care and hospice services?

Ajeet Gajra, MD, MBBS, FACP: Timely referrals to palliative and hospice care close to end-of-life are considered a quality benchmark in oncology. So, our own society, ASCO, through their QOPI program, have established that there are ASCO guidelines, NCCN guidelines, about integrating palliative care early on in the course of patients fighting cancer. And what it leads to is a better expectation of, you know, a level set of expectations of the patients and the families better, number 1. Number 2, it avoids many times traumatic treatments close to end of life.

So, what we do know is if patients with advanced cancer are receiving chemotherapy, radiation therapy, if they are having repeated visits to the emergency room, getting hospital admissions, ICU admission, those are all bad outcomes. Those outcomes denote poor quality of oncology care delivery, actually, and so they should be avoided at all costs and prevented. So, the way to avoid and prevent these is by integrating palliative care early on in the course. And when the time comes, that palliative care can then be transitioned into hospice care when appropriate. And I think that is a critical piece. And unfortunately, there's still, you know, sometimes confusion about equating palliative care with hospice care. And again, I will highlight that hospice care is just a little segment of palliative care, which is a much broader term in something that that much longer continuum, and towards the end of that, you know, we utilize hospice care.

What obstacles inhibit these timely referrals for patients with advanced cancer?

Ajeet Gajra, MD, MBBS, FACP: So I would break those obstacles into really 3 buckets. So, there are obstacles or barriers from a patient or, you know, a caregiver perspective. There are obstacles from the provider or the clinician perspective. And then there are obstacles which are, you know, system-imposed obstacles. So, if we talk about patients and caregivers first, there is always that concern that if palliative care is not mentioned in the appropriate context, or how it is conveyed to them, that there's a fear that my doctor is giving up on me. So, you know, that is, unfortunately, still a prevalent thought process. I think, through our outreach and patient directed education, we need to eliminate that and reduce that kind of mindset. I think we need to make it very clear to patients and families that if their clinical team is recommending palliative care, alongside other therapy that they're getting, the goal is to really help them manage symptoms more effectively, and actually enhance the quality of care. And it doesn't mean that, you know, their oncologic care is being discontinued.

So then, I think there’s the flip side. So, I said, you know, there's also the clinician or the provider aspect. So, providers also need to believe that palliative care is an essential component of the cancer fighting continuum. And when integrated early on, we have many studies, you know, seminal work came first, in patients with advanced lung cancer, and this is now 10 years ago. And since then, we have many other studies to demonstrate that the earlier integration of palliative care enhances outcomes, both in terms of quality of life and perhaps also survival for these patients. So, I think we need to do that.

In some other work that Cardinal Health has done with community oncology clinicians, there's still a deficit in which folks are not integrating a palliative care early on. They're waiting until, you know, really later stages and close to end of life before initiating such care. And so that is still clinicians and providers, perhaps specialty in a community setting. And, you know, the United States is a large country and there are many practices, and especially in the rural areas where these are busy practices and these clinicians are busy taking care of all kinds of cancer patients and so this may be not top of mind for them. So education feels critical.

And the third, like I said, is a systems-based issue. Do we have enough palliative care providers? You know, it doesn't have to be physicians, it can be advanced practice providers. It can be a team, you know, which includes an APP and the social worker and other components. But there has to be recognition that this is a critical component in the care of the patient.