Creating a smooth transition for patients from one cancer care setting to another is an important part of continuity of care. Although delivery of cancer care is improving, recent studies show that gaps still exist in the transition to palliative care. Oncology fellows can help bridge these gaps by enhancing their communication skills.

“Many cancer centers report having palliative care programs, although the infrastructure of those programs remain deficient in multiple ways,” said David Hui, MD, assistant professor in the Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, in Houston, Texas. He led a recent study, published in the Journal of the American Medical Association, that analyzed the availability and integration of palliative care at US cancer centers.1

One gap identified in the study was infrastructure. Outpatient palliative care clinics are uncommon in cancer centers and often are not open 5 days per week. In the study of 142 cancer centers, only 23% had dedicated palliative care beds, and only 37% had an institution-run hospice. Dr. Hui’s study also noted gaps in timing. The median time from inpatient palliative care referral to death was 7 days.1 “Typically, the time from first consultation to death is a week,” Dr. Hui said. “That is a very short time and limits the ability of palliative care to help patients.”

Additionally, the Hui study found that research programs, palliative care fellowships, and mandatory rotations for oncology fellows were rare.1 This education gap also was identified in a recent study in the journal Cancer.2 In a survey involving 254 second-year oncology fellows, only 26% had completed a palliative care rotation, and fellows rated the overall quality of the education they received on palliative care significantly lower than the overall quality of the fellowship.2 Fifty-seven percent of the fellows said that psychosocial needs were conveyed as a core competency, but only 32% received explicit education on assessing and managing depression at the end of life.2 Only 33% of the fellows had received education on opioid rotation, and only 23% could correctly do an opioid conversion.2

So, how can oncology fellows bridge the gaps? First, they need to be aware of which patients are most likely to have palliative care needs (PCNs). In a study of nearly 12,000 cancer patients who were discharged from one of the largest hospitals in Europe, 15.8% were classified as having PCNs by their doctors.3 Needs were particularly high in patients with head and neck cancer (28%), malignant melanoma (26%), and brain tumors (18%).3

Fellows can also hone their communication skills so they can successfully talk to patients about transitioning from disease-modifying therapy to end-of-life care (Table). A recent study showed that oncology fellows who have not received communication training used 1 of 2 approaches when discussing this transition: a logical frame or an experiential frame.4 According to the researchers, fellows relying on a logical frame—we can no longer do this, so now lets do this—may find that patients hesitate to follow because they feel the physician has categorized them as a treatment failure, rather than a unique individual. Physicians relying on an experiential frame—you’re experiencing this, so let’s focus on your goals aside from disease reversal—may find that patients may not heed advice because therapy limitations are unclear or the physician has suggested goals that fail to resonate with the patient.4 Data for this study was gathered from videotapes of oncology fellows in mock transition discussions before they participated in Oncotalk, a 4-day intensive communication skills workshop.4

Table. Tips for Improving “Transition Conversations”
Ascertain what a patient knows about his or her disease
Observe an exemplary oncologist having a “transition conversation” with a patient
Practice “transition conversations” and ask for feedback from nurses or social workers

Based on a conversation with Robert Arnold, MD.

“What we found is that in the conversation beforehand, people focus on details and don’t focus on broader questions of goals,” said Robert Arnold, MD, chief of the Section of Palliative Care and Medical Ethics at the University of Pittsburgh School of Medicine who led the study. “After they had the training, they were much better at being able to deal with emotions and much better at not just offering more chemotherapy when a patient says, ‘isn’t there something else you can do?”

According to Dr. Arnold, the first step in having a transition conversation is ascertaining what a patient understands about his or her disease. “The first thing would be to say, ‘Can you tell me what other people have been telling you about where your cancer is?” Dr. Arnold said. Then, an oncologist should provide information in small bits, without jargon, and then be ready to react to an emotional response from their patient.

Dr. Arnold recommends that fellows learn by watching transition conversations. “In all fellowships, there are probably oncologists who [fellows] think are really good at having these conversations. Focus on exactly what they do, what they say, and how those words work,” said Dr. Arnold. He also suggests that fellows practice and ask for feedback. “When fellows have those conversations, they can ask the nurses or social workers to watch them and give them feedback. I think this is something that requires practice, and if they are not practicing, then they are not going to get better.”

References

     
  1. Hui D, Elsayem A, De La Cruz M. Availability and Integration of Palliative Care at US Cancer Centers. JAMA 2010;303(11):1054-1061.
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  3. Buss MK, Lessen DS, Sullivan AM, et al Hematology/oncology fellows’ training in palliative care: results of a national survey. Cancer 2011;117(18):4303-4311.
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  5. Becker G, Hatami I, Xander C, et al. Palliative cancer care: an epidemiologic study. J Clin Oncol. 2011;29(6):646-650.
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  7. Back AL, Michaelsen K, Alexander S, et al. How oncology fellows discuss transitions in goals of care: A snapshot of approaches used prior to training. J Palliat Med. 2010;13(4):395-400.
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