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Volume 10, Issue 2
National Guidelines Updated
to Emphasize Cancer Patients’ Needs
for Palliative Care and Transition to Hospice
A not-for-profit alliance of 27 leading
U.S. cancer centers has issued its latest
Clinical Practice Guidelines in Oncology,
including guidelines recommending early
hospice and palliative care. The National
Comprehensive Cancer Network (NCCN)
updates its guidelines at least annually,
based on a review of the most recent clini-
cal evidence by its interdisciplinary panel
of experts in the field.
“These recommendations were revised
to provide clearer guidance for oncolo-
gists as they care for patients with cancer
who are approaching the transition to
end-of-life (EOL) care,” write the authors
of an article published in the NCCN’s of-
ficial journal.
“Recommendations for interventions
and reassessment based on estimated life
expectancy were streamlined and repriori-
tized to promote hospice referrals and im-
proved EOL care,” continue the authors,
whose article discusses highlights of the
revised guideline’s goals and changes.
CANCER PATIENTS’ NEED FOR
PALLIATIVE CARE
The stance of the NCCN is that im-
proved access to palliative care and hospice
may help cancer patients and their families
deal with symptoms and challenges.
“Generally speaking, earlier incorpora-
tion of palliative care in the cancer care
continuum has been associated with im-
proved EOL outcomes,” write the authors.
“Palliative care has been shown to reduce
symptom burden, improve quality of life
(QOL), and increase the odds of dying at
home.” In addition, they note, multiple
studies have shown that hospice care is
associated with QOL benefits including
fewer hospitalizations, fewer invasive
procedures, and less high-intensity care.
Many cancer patients still receive ag-
gressive treatment near the EOLand do not
receive hospice care early enough, which
is cause for concern, the authors note. In
2014 the median length of stay for hospice
patients was only 17.4 days, and more than
one-third of hospice patients were en-
rolled for seven days or fewer. “Targeted
interventions may lead to enhanced use of
hospice care and improved EOL experi-
ences for patients and their families,” the
authors suggest.
NCCN RECOMMENDATIONS
The NCCN provides an algorithm to
help clinicians apply important steps of
palliative care at the appropriate time dur-
ing the disease trajectory. The following
are some of the updated palliative care
recommendations for clinicians, based on
the patient’s prognosis.
•
Patients with an estimated prognosis
of years, or years to months.
Assess
the patient’s and family’s awareness of
prognosis and disease course. Engage in
regular discussions about prognosis, ad-
vance care planning, and the potential for
a surrogate decision-maker. Assess the
patient’s and family’s values and pref-
erences. Assess the need for specialized
palliative care or hospice care.When the
patient has a prognosis of 6 to 12months,
consider having a “hospice information”
visit to ease the care transition.
•
Patients with an estimated prognosis
of months to weeks, or weeks to days.
“Referral to hospice agencies should be
a priority,” state the authors. Assess pa-
tient/family understanding of the dying
process, and educate those who desire to
know more. Consider the need for care
transitions, while keeping patients’ pri-
mary care and oncology teams involved.
Be prepared to offer information or
referrals for psychosocial assessment,
grief counseling, funeral planning, and
other support. Keep the goals and needs
of patient and family in mind. Ensure
the patient does not die alone unless that
is their established preference.
The NCCN suggests regular reas-
sessment and clear communication. It
recommends intensifying palliative care
interventions if patients and families do
not experience benefits, such as reduced
distress, decreased caregiver burden, and
optimized QOL.
UPDATES TO PALLIATIVE CARE
GUIDELINES
The 2017 updates reflect the panel
members’ desire to emphasize the need to
support patients through care transitions
and EOL care. Changes to the guidelines
include:
•
An algorithm page previously titled
more broadly was renamed
“Prepar-
ing Patients and Families for End of Life
and Transition to Hospice Care.” This
change streamlines suggestions and
emphasizes patients’ need for support
during the transition to EOL care and
hospice services.
•
“Refer to hospice agencies”
is now
the first recommendation for patients
with shorter prognoses. This change
highlights the importance of an early
referral to hospice.
•
Patients with a life expectancy of
“months to weeks”
were added to
the group previously containing only
patients with a prognosis of “weeks to
days.” This may help cancer patients
receive hospice and other EOL care
earlier in their disease course.
The NCCN panelists also stressed the
need to consistently communicate with
patients and families about goals, values,
and expectations, which are likely to shift
throughout the disease course.
The complete version of the updated
NCCN Guidelines for Palliative Care can
be found at
www.NCCN.org.Source: “NCCN Guidelines Insights Palliative
Care, Version 2.2017: Featured Updates to
the NCCN Guidelines,”
Journal of the National
Comprehensive Cancer Network;
August 2017;
15(8):989–997. Dans M, Smith T, Back A,
Scavone JL, et al; National Comprehensive
Cancer Network, Fort Washington, Pennsylvania.