Reducing Costs by Better Integration of Palliative Care in Cancer Treatment

We’re up to point 9 on the list – and nearing the end – on Bending the Cost Curve in Cancer Care from the May 26 NEJM. The suggestion from Drs. Smith and Hillner is that doctors better integrate palliative care into usual oncology care.

The authors start this important section well:

We can reduce patients’ fears of abandonment by means of better-integrated palliative care. This topic is fraught with misunderstanding given the references to “death panels” during the recent debate concerning health care legislation…

Here they’re on target: Some patients think, mistakenly, that inclusion of palliative care in their treatment means their doctors are throwing in the towel. I’ve known some oncologists who think the same, who perceive palliative care as a last resort.

The truth is that palliative care, which aims to relieve symptoms, can be implemented at any point in the treatment of disease.

The authors go on to provide data that cancer patients who receive palliative care live just as long, or longer, than those who don’t, and that their medical bills are lower. The issue I have here is their choice of emphasis on a published study of the Aetna Compassionate Care Program in which nurses identified patients for palliative care by administrative claims, “thus bypassing the oncologist.” Evidently this strategy led to a doubling of hospice referrals and other possibly good effects.

Besides that the cited study was authored by employees of an insurance company, which I find unpalatable, the concept of having nurses do the referrals deflects the issue: that oncologists talk about palliative care with their patients, directly. Relying on nurses to carry out these conversations would, understandably, contribute to a sense of abandonment, even if the nurses do the job perfectly. A critical role oncologists is to communicate about treatment care options, part of the cognitive work considered in point 8 of this discussion.

But the main idea, that doctors should integrate palliative care into their cancer patients’ treatment planning, earlier, and as a supplement – and not a replacement – for potentially curative or tumor-shrinking strategies, is right on.

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Lowering Cancer Care Costs by Limiting Chemotherapy in Patients Who Aren’t Responding

This is the sixth post on Bending the Cost Curve in Cancer Care, based on the 10 suggestions put forth by Drs. Smith and Hillner in the May 26 NEJM.  We’re up to number 5 on the list for changing oncologists’ behavior: by limiting further chemotherapy to clinical trial drugs in patients who are not responding to three consecutive regimens.

They’re right.

Giving one drug or combination regimen, and then another, and another, and another, to cancer patients whose tumors resist multiple regimens is more likely to cause harm than good. Oncologists need be realistic with themselves and with their patients, in a kindly way, when treatments fail.

Options to consider, besides chemo, include palliation (which can be started at any time, including before and during chemotherapy), alternative approaches (such as hormonal or immune-based therapy, for some tumors), hospice care and participation in a clinical trial, as the authors suggest, based on the patient’s condition and preferences.

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Engage with Grace: Talking About the Hard Stuff

When I practiced oncology, I relished time spent talking with patients and their loved ones about tough decisions – when an indolent condition accelerated and it seemed time to start treatment, or when a cancer stopped responding to therapy and it seemed right to shift gears and, perhaps, emphasize palliation instead of more chemo, and at every value-loaded decision checkpoint in between.

These conversations weren’t easy; speaking of levels of care, palliation and end-of-life wishes are discussions that many doctors, even oncologists, still avoid. But I, in what I hope was a healthy way, always enjoyed that part of my work. My thinking was that even if I couldn’t change the course of an aggressive tumor, I might make a difference in the quality of a person’s end of life.


At Thanksgiving, when family and old friends come together, we face similar choices in the topics we discuss: we can chat about the weather, or delve into relatively heated topics like global warming, politics or religion, but it’s rare that we get into the existential stuff, where my thoughts tend to wander, or into the most-avoided topics of all: what to do when our loved ones get really sick.

This weekend, Medical Lessons is participating in its first blog rally. I learned about this last year from Paul Levy, who’s Running a Hospital in Boston, and was reminded earlier today in an email from Dr. Christian Sinclair of Pallimed. The purpose of the rally is to draw attention to the Engage With Grace project, which is, ultimately, about communication in non-trivial health decisions.

From the Engage With Grace website:

  • 73% of Americans would prefer to die at home, but anywhere between 20-50% of Americans die in hospital settings.
  • More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they’ve talked to them about their preferences.
  • Eight out of ten people say it is “very” or “somewhat” important to write down EOL wishes, but only 36% actually have written instructions.

The project goal is to get the conversation started – to get families talking about values and medical decisions when they’re together over the Thanksgiving holiday, instead of waiting until there’s an emergency and they’re forced to make critical decisions under pressure and without clear directive.

I don’t mean to suggest that this is an ideal or even a good subject for conversation at the Thanksgiving table, or in a house filled with neighbors or casual acquaintances. (I don’t think it is.) But maybe when you’re washing dishes in the kitchen with your brother, or driving your mom to the airport, or sitting on the bus with your son…

There’s never a good time, or enough time, to talk about these kinds of things. But these matter a lot, especially if you or someone you love becomes really sick, which happens sooner or later to most mortals. PBS aired a special on this topic last night, on the kinds of tough decisions families face when someone is acutely ill, which is available on-line and I suggest to my readers.

For tomorrow, my recommendation is to enjoy the holiday, as I intend to do!, and to eat lots of fresh fruits and vegetables, and to connect with the people you care about and don’t see as often as you’d like or wish you could –

And maybe on Friday, or Saturday, some of you will begin that difficult conversation.

Happy Thanksgiving!


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How to Avoid Death in the ICU

Something I learned as a medical intern is that there are worse things than dying.

As I recall, it was sometime in April, 1988. I was putting a line in an old man with end-stage kidney disease, cancer (maybe), heart failure, bacteria in his blood and no consciousness. Prince was on the radio, loud, by his bedside. If you could call it that – the uncomfortable, curtained compartment didn’t seem like a good place for resting.

An attending physician, a smart guy I respected, approached me as I completed the procedure.

“It’s kind of like Dante’s seventh circle,” he noted.

Indeed. A clear, flexible tube drained greenish fluid from the man’s stomach through his nose. Gauze covered his eyes, just partially. His head, hands and feet swelled with fluid. A semi-opaque hard-plastic instrument linked the man’s trachea, through his paper-taped mouth, to a noisy breathing machine. His skin, barely covered by a stained hospital gown, was pale but blotchy from bleeding beneath. An arterial catheter inserted by his wrist, just where I might have taken his pulse had he been healthier. A fresh adhesive covered the cotton gauze and brownish anti-bacterial solution I’d placed over his lower right neck.

“Yeah,” I said as we walked out of the room to review another patient’s chart.

I wondered if the ICU staff would mind my changing the radio station, just in case the patient could hear but not tell us he preferred WQXR.

“There’s no way I would let this happen to me,” I remember thinking.


This month, a report in the ACS journal Cancer indicates that most U.S. physicians don’t talk with their patients about end-of-life issues until death is imminent, if they do so at all.

The study, based on canvassing over 4000 doctors who care for cancer patients in California, North Carolina, Iowa and Alabama revealed that only a minority of physicians would raise the subject of a DNR (do not resuscitate) order or the possibility of hospice care for a patient with metastatic cancer with a life expectancy of 4-6 months. The article has generated considerable, appropriate attention in the press and for good reason – it bears on health care costs, patients’ rights, doctors’ communication and time constraints and a host of points relevant to the practice of medicine in 2010.

For purposes of this post, today, what I’ll say is this much:

Don’t wait for your doctor to talk to you about death and dying. Be proactive about your wishes and the kind of care you wish to receive, especially if you’re sick with a serious medical condition. Take the initiative – document your end-of-life preferences as best you can, according to the law of your state, and tell your physicians about any limits you’d like to set on the care you might receive.

It’s a conversation worth having, early.


Here’s a very-partial list of resources for people who’d like to learn more about advance directives, living wills, DNR orders, hospice care and other end-of-life concerns:

MedlinePlus on Advanced Directives;

New York State: information on Health Care Proxy forms and DNR orders

Family Caregiver Alliance on End-of-Life Choices

Hastings Center on End of Life Issues

American Hospice Foundation

Cisely Saunders Foundation

Hospice Foundation of America

The National Hospice and Palliative Care Organization

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