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Invited Commentary
Feb 25, 2013

Palliative Care: An Approach for All Internists: Comment on “Early Palliative Care in Advanced Lung Cancer: A Qualitative Study”

Author Affiliations
Author Affiliations: Division of Geriatrics, Department of Medicine, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco.
JAMA Intern Med. 2013;173(4):291-292. doi:10.1001/jamainternmed.2013.1888

In 2010, Temel and colleagues1 published what many believe is the most influential article in palliative care (PC) since the 1995 publication of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT).2 Temel and colleagues randomized 151 patients at the Massachusetts General Hospital with metastatic non–small cell lung cancer to receive early outpatient PC or standard care. Patients randomized to PC had significant improvement in quality of life and lower rates of depressive symptoms compared with those who received standard care. These findings confirmed the benefits that many clinicians suspected from anecdotal experience. What shocked many was the finding that despite receiving less aggressive end-of-life care, patients randomized to PC had a longer median survival than patients in the standard care group.

The survival finding challenges the deeply held assumption of a tradeoff between palliative approaches to care and aggressive “life-prolonging” treatments. This assumption is buried deep in the language clinicians use in everyday discussions about goals of care, such as “All things considered, do you want to focus on quality of life and comfort, even if it means not living as long? Or living as long as possible, even if it may mean enduring more pain and discomfort?” In contrast, the survival finding suggests that, for certain patients, not only is there no evidence that PC shortens life, but for some patients, there is evidence that PC prolongs life. There may not be an “either/or” tradeoff between quality of life and length of life.

Evidence suggests a trend toward more aggressive end-of-life treatment. In a study of 215 484 Medicare patients who died of advanced cancer in the Surveillance, Epidemiology, and End Results data set, rates of chemotherapy within 14 days of death increased between 1993 and 2000, as did rates of emergency department use and hospitalization in the last 30 days of life.3 Presumably, chemotherapy, emergency department use, and hospitalization are directed toward prolonging life. Yet, there are 2 main hypotheses that might explain the survival findings in the study by Temel et al.1 The first was whether increased survival was due to improved recognition and treatment of depression and improvements in quality of life. The second was whether prolonged survival was due to lower rates of chemotherapy, emergency department use, and hospitalization in the last weeks of life.1 If the latter is the case, then more aggressive treatment and hospital care presumed to prolong life may actually have the opposite effect for some.

To be sure, the findings of improved survival in the study by Temel et al1 need to be replicated. Although there was some suggestion from the previous literature that a palliative approach might lead to prolonged survival,4,5 this was the first randomized trial to demonstrate this finding. The biggest question raised by the findings in the study by Temel et al was whether these findings were replicable outside a single institution, the Massachusetts General Hospital.

A study by Yoong and colleagues6 in the current issue of the journal provides tantalizing hints about the answers to this question. In the original randomized trial, we had little data about what exactly the outpatient PC clinicians did in the clinic. In the study published in this issue of the journal,6 the authors conducted a retrospective qualitative content analysis of the clinic visit notes of 20 patients in the PC group of the randomized trial. Clinic notes suggest that the outpatient PC visits followed a semistructured yet flexible approach to outpatient encounters, and when the cancer and symptoms worsened, PC clinicians and oncologists documented a different focus to their conversations.

The progression of PC clinic visits from initial encounter to death are in some ways a model for how all effective outpatient visits should proceed for patients with serious illness. Initial visits were focused on building a relationship with the patient, understanding the larger social context of the illness experience, and how the cancer affected their lives. Clinicians established preferences for decision making and patient understanding of prognosis. Symptoms and coping were addressed across all visits. When the patient's clinical condition deteriorated, both oncologists and PC clinicians addressed plans for end-of-life care. However, oncologists' notes emphasized discussion of medical complications of radiographic progression of disease, whereas PC clinicians' notes emphasized the psychosocial effect of worsening health on the patient and family.

The study of these clinic notes is as remarkable for what the authors found as what they did not. On the basis of the survival findings from the randomized trial, one might have expected early outpatient PC encounters to introduce the idea of hospice and establish specific plans for end-of-life care. Notes do not indicate that such discussions took place early in the treatment process, however. After clinical deterioration, these issues were addressed by both the oncologists and PC clinicians.

A number of issues limit the interpretation of these findings. The study did not include a comparison of outpatient medical records of patients in the standard care group. Oncologists in the palliative arm were aware that their patients were in the PC group or standard care group, which may have influenced the content of the oncologists' discussions. In addition, we do not know whether what was documented in the notes is an accurate reflection of the discussions that occurred. Even if the notes are accurate, the subtlety, emotion, and nonverbal aspects of the encounters are not captured. As described by Gawande,7 communication about goals of care is a skill that does not come easily to most clinicians, and, like other aspects of medicine, requires intense training to learn to do well. Yet, the study by Yoong et al6 does not suggest that the issues addressed are out of the realm of most internists. With proper training, perhaps any internist could learn to address these issues. This hypothesis is empirically testable.

While we are waiting for the science in this area to progress, the general approach described by Yoong et al6 has such strong face validity that all internists should consider incorporating it into their practices. The focus of PC is not browbeating patients into accepting hospice and avoiding resuscitation or hospitalization, as some might assume. Palliative care is at its heart a relationship-centered profession. Palliative care clinicians build strong relationships with patients and families in the hopes of finding a way through the symptoms and distress, a way to cope with the illness experience, and a way to make each day as good as it can be. Many patients with serious illness will not have access to an outpatient PC clinician, but they will probably have access to an internist. Patients might benefit if all internists incorporated this approach, seeking supplementary training in PC. And some benefits, like survival, might be surprising.

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Article Information

Correspondence: Dr Smith, Department of Medicine, University of California, San Francisco, 4150 Clement St (181G), San Francisco, CA 94941 (aksmith@ucsf.edu).

Published Online: January 28, 2013. doi:10.1001/jamainternmed.2013.1888

Conflict of Interest Disclosures: None reported.

Online Only Material: Listen to an author interview about this article, and others, at http://bit.ly/OsqSNt.

References
1.
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;363(8):733-74220818875PubMedGoogle ScholarCrossref
2.
The SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).  JAMA. 1995;274(20):1591-15987474243PubMedGoogle ScholarCrossref
3.
Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue?  J Clin Oncol. 2008;26(23):3860-386618688053PubMedGoogle ScholarCrossref
4.
Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and nonhospice patient survival among patients who die within a three-year window.  J Pain Symptom Manage. 2007;33(3):238-24617349493PubMedGoogle ScholarCrossref
5.
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;302(7):741-74919690306PubMedGoogle ScholarCrossref
6.
Yoong J, Park ER, Greer JA,  et al.  Early palliative care in advanced lung cancer: a qualitative study [published online January 28, 2013].  JAMA Intern Med. 2013;173(4):283-290Google Scholar
7.
Gawande A. Letting go: what should medicine do when it can't save your life? The New Yorker. July 26, 2010:36-49. http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande
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