FEATURE
Palliative Care:
Time for Hematology to Step Up
When the Centers for Medicare and Medicaid
Services (CMS) finalized its payment schedule for
advanced-care planning in November, establishing separate payment for these discussions and
services,1 the response among the palliative-care
community was likely a resounding, “Finally!”
The action recognized the time that practitioners spend conducting advanced-care conversations, and is expected to encourage discussions
among physicians, patients, and caregivers about
supportive and end-of-life care.
While the intended audience of the payment
ruling were specialties that have more formally integrated palliative care systems into general treatment
protocols – solid tumor oncology and intensive care,
for instance – its effect on the treatment of patients
with hematologic malignancies remains to be seen.
Historically, integrating palliative care into this
segment of hematology has been a struggle, for a
variety of reasons, according to experts who spoke
with ASH Clinical News.
Better Living Through Palliative Care
“With patients with hematologic malignancies, the
natural history of their disease is a bit different,”
explained Anthony Back, MD, professor in the Department of Medicine, division of oncology, at the
University of Washington in Seattle, Washington.
“Solid-tumor patients will generally experience a
slow decline, where it eventually becomes evident
on a functional level that they are weakening.”
For patients with hematologic malignancies, however, the decline is less obvious, leading
some hematologists to choose to continue active
treatment, Dr. Back explained. “These patients
will continue to receive anti-cancer treatments or
blood products very close to the end of life. Most
hematologists agree that palliative care offers some
benefits, but believe they are short-lived, so their
first instinct is to just go with more or different
anti-cancer treatments.”
Another concern? Turf issues. “My [hematology]
colleagues tend to assume that palliative care specialists are going to take their patients away,” added
Thomas LeBlanc, MD, cell therapy and hematologic
malignancies specialist, hematologist, medical oncologist, and palliative medicine specialist at Duke
Medicine in Durham, North Carolina. “Hematologists need to know that palliative care is not about
the end of life for the patient – it’s about living a
better life even while living with cancer.”
Hematology’s outlook on palliative care is slowly
changing. First, researchers have begun documenting the barriers to palliative care that the hematology community needs to overcome to move forward
with the practice. In addition, for the first time, this
year’s ASH annual meeting will feature an Education
104
ASH Clinical News
Program session devoted solely to palliative care in
hematologic malignancies, chaired by Dr. LeBlanc
(Read more about the session in the 2015 ASH Annual Meeting Preview on page 72).
Palliative care can be helpful to physicians and
patients on many fronts: symptom management
(including severe or refractory symptoms); supporting family caregivers; helping patients with anxiety,
depression, and mood-related issues; and transition
of care upon relapse, Dr. LeBlanc pointed out.
Perceptions and Misperceptions
According to Douglas Brandoff, MD, co-director
of the Palliative Care Clinic at the Dana-Farber
Cancer Institute in Boston, however, many people
might have the wrong impression of exactly what
palliative care entails.
“At one end of the spectrum, there are patients who say, ‘Palliative care? What’s that?’ And
at the other end of the spectrum are people who
hear ‘palliative care’ and think ‘death panels,’” Dr.
Brandoff said. “There’s a very rich, fertile middle
ground with palliative care and an incredible
amount of value that we can add when we provide
palliative care upstream.”
“At one end of the
spectrum, there are
patients who say, ‘Palliative care? What’s
that?’ And at the other
end of the spectrum
are people who hear
‘palliative care’ and
think ‘death panels.’”
—DOUGLAS BRANDOFF, MD
One of the fundamental issues preventing greater upstream use of palliative care in hematologic
malignancies is an incorrect understanding of what
palliative care is, according to Dr. LeBlanc. Historically, blood cancer specialists have judged palliative
care as being synonymous with hospice, but the
latter is just a small part of an array of options.
“Palliative care is specialized medical care for
patients with serious illness,” Dr. LeBlanc explained. “It can be provided at any stage of care,
even along with active cancer treatment. It’s not
just end-of-life care, and that’s the fundamental
disconnect for hematologists.”
Engaging in palliative care in no way means
that the hematologist is giving up on the patient,
though that may be the perception, he added. Often, clinicians will perpetuate their misunderstanding of palliative care to their patients and avoid the
conversation entirely.
Bronwyn Long, RN, DNP, MBA, a palliative
care and