The ESMO Palliative Care initiative Nathan I Cherny Shaare Zedek Medical center Jerusalem, Israel
ESMO PC/SC Working Group
Established 1999 by ESMO national representatives
Chair: Prof Raphael Catane
Palliative Care Working Group Active members Lange Winand K, Germany Wagnerova Maria, Slovak Republic Szanto Janos, Hungary Schrijvers Dirk, Belgium Rubach Maryna, Poland Parikh Purvish, India Ozyilkan Ozgur, Turkey Kloke Marianne, Germany Grigorescu Alexandru, Romania Cherny Nathan, Israel Catane Raphael, Israel
Integration of oncology and Palliative Care: ESMO view
Medical oncologists role is to coordinate patient care at all stages of the disease along with other relevant disciplines
Increasingly oncologists are being marginalised because the profession is seen as “chemotherapists”
To maintain a central coordinating role oncologists need to be perceived as “cancer specialists” with a breadth of expertise, perspective, and commitment.
The scope of specialist cancer care
In advanced cancer
Palliative anti tumor treatments
End of life care
Unless oncologists take a lead role in the coordination and implementation of these aspects of care, we undermine our claim to be “cancer care” specialists .
Definition of Terms
care that optimizes comfort, function and social support of patient (and family) at all stages of illness
care that optimizes comfort and function and social support of patient (and family) when cure is not possible
End of Life Care
palliative care when death is imminent
Supportive Care Palliative Care Diagnosis PotentiallyCurable Non-Curable Terminal EoL Care
Care Integration with Disease Evolution Supportive Care Curable disease: Cured Curable disease: Relapsed Supportive Care Palliative Care EoL Supportive Care Palliative Care EoL Curable disease: Failed Palliative Care EoL Incurable disease
“ The Role of the Oncologist in the Provision of Supportive and Palliative Care”
The Medical Oncologist must be skilled in the supportive and palliative care of patients with cancer and in end-of-life care.
It is the responsibility of the MO to assess and evaluate physical and psychological symptoms and to ensure that these problems are adequately addressed.
The delivery of high quality supportive and palliative care requires co-operation and coordination with:
physicians of other disciplines
(including radiotherapy, surgery, rehabilitation, psych-oncology, pain medicine and anesthesiology, palliative medicine etc)
(including nursing, social work, psychology, physical and occupational therapy, chaplains and others).
Supportive and Palliative Care training for Medical Oncologists
Medical Oncologists must be skilled in the supportive and palliative care of patients with advanced cancer.
9 core skills must be incorporated.
1.The oncologic management of advanced cancer
Medical oncologists must be expert in the appropriate use of anti tumor therapies as palliative techniques when cure is no longer possible.
This includes specific familiarity with key concepts
quality of life
2. Communication with patients and family members
Medical oncologist must be skilled in effective and compassionate
communication with cancer patients and their families.
Specific skills include:
Explaining diagnosis and treatment options
Disclosure of diagnosis
Explaining issues relating to prognosis
Explaining the potential risk and benefits of treatment options
Counseling skills to facilitate effective, informed decision making.
Explaining the role of palliative care
The care of distressed family members: fear, anticipatory grief, bereavement care
Convening of family meetings
3 . The management of complications of cancer
Medical oncologists must be expert in the evaluation and management of the complications of cancer including:
Neurological dysfunction: tumoral, paraneoplastic and iatrogenic
Liver metastases and biliary obstruction
Obstruction of hollow viscera
Metabolic consequences of cancer
Anorexia and cachexia
4. Evaluation and management of physical symptoms of cancer and cancer treatment
Medical oncologists must be expert in the evaluation and management of the common physical symptoms of advanced cancer including:
Dyspnea and cough
Nausea and Vomiting
5. Evaluation and management of psychological and existential symptoms of cancer
Medical oncologists must be familiar with the evaluation and management of the common psychological and existential symptoms of cancer including:
Suicidality and desire for death
6. Interdisciplinary care
Medical oncologists must be familiar with the roles of other professions in the care of patients with cancer and with community resources to support the care of these patients.
7. Palliative care research
Medical oncologist must be familiar with research methodologies that are applicable to patients with cancer including:
Quality of life research
Pain measurement and research
Measurement of other physical and psychological symptoms
Decision making research
Palliative Care audit
8. Ethical issues in the management of patients with cancer
MOs must be familiar with common ethical problems and ethical principles that assist in their resolution:
Related to disclosure of diagnosis and prognosis
In decision making: paternalism, autonomy, informed consent
The right to adequate relief of physical and psychological symptoms and its implications
Consent: informed, uninformed
Ethical issues at the end of life
Euthanasia, assisted suicide
9 .Preventing Burnout
Medical oncologist must be familiar with the symptoms of burnout, the factors that contribute to burnout and strategies to prevent its development.
Minimal requirements palliative care in cancer centers 1
Patients should be routinely assessed regarding the presence and severity of physical and psychological symptoms and the adequacy of social supports
When inadequately controlled symptoms are identified they must be evaluated and treated with the appropriate urgency
Cancer center must provide skilled emergency care of inadequately relieved physical and psychological symptoms.
Minimal requirements palliative care in cancer centers 2
Cancer centers must ensure an ongoing program of palliative and supportive care for patients with advanced cancer who are no longer benefited by anti-tumor interventions.
Cancer centers should incorporate social work and psychological care as part of routine care.
When patients require inpatient end of life care, the cancer center staff either provide the needed inpatient care or arrange adequate care in an appropriate hospice or palliative care service.
Research ESMO Palliative and Supportive Care Survey :
the degree to which ESMO oncologists are involved in the management of advanced cancer
the degree with which they collaborate with PC clinicians
their personal involvement in PC
their attitudes to PC
place of work
involvement in advanced cancer
Survey tool 2
Collaboration with SC/PC
Practice of SC/PC
Sex: F 194 (21.7%) M 701 (78.3%)
Median age: 45-49
Median experience: 15-19 years
Private oncology practice 167 18.7%
Community hospital based 176 19.7%
Teaching hospital based 334 37.3%
Comprehensive cancer center 185 20.7%
Other………………………… 33 3.7%
Proportion of my practice involved with advanced (incurable) cancer
None 4 0.4%
A small proportion 78 8.7%
A substantial proportion 615 68.8%
Most of my practice 197 22.0%
Most medical oncologists are clinically involved with patients with advanced cancer
The attitudes of responding members correspond closely with the proposed ESMO policy statements relating to Supportive Care/Palliative..
integration of SC/PC in cancer centers
Most MOs believe that
oncologists should coordinate care the care of patients with advanced cancer including EoL care
SC/PC should be initiated in all patients when need is identified
oncologists should be expert in physical and psych SC/PC
all cancer centers should provide SC/PC
Discrepancy Between Attitude and Practice
Although, 88.4% agreed medical oncologists should coordinate the care of cancer patients at all stages of disease including end of life care...
Actual practice seems much less...
43% commonly coordinate the care of cancer patients at all stages of disease including end of life care.
39% commonly coordinate meetings with the family of dying patients
11.8% manage delirium
A social worker 47.9
A home hospice (palliative care) team 37.8
A palliative care medical specialist 35.1
A psychologist 33.3
A palliative care nurse specialist 31.7
An inpatient hospice 26.4
A psychiatrist 14.9
Attitudes: No Consensus
I received good training in PC during my oncology fellowship (residency)
I feel emotionally burned out by having to deal with too many deaths.
Most MOs I know are expert in the management of the physical and psychological symptoms of advanced cancer.
A palliative care specialist is the best person to coordinate the palliative care of patients with advanced cancer.
Palliative care (or Hospice) physicians don’t have enough understanding of oncology to counsel patients with advanced cancer regarding their treatment options.