When should treating a cancer patient become more about controlling symptoms and making the patient comfortable than about trying to slow the cancer itself?
Hospitalists, who often care for patients in the worst stages of health, regularly make important observations that result in a patient transitioning to hospice care. When such a case is suspected, careful discussions with the treating oncologist, the patient, and the patient’s family should be held.
Determining how and when to have those discussions can be tricky, experts say.
“You have to understand the family dynamic before anything else,” Dr. Sahitya Gadiraju, DO, says. “You have to understand the patient, how mentally and emotionally ready they are to have that conversation. And how ready [the family] is to have that conversation.”
“The best treatment, regardless of anything else, is really symptom control, palliative care, taking care of the anxiety, the pain, the sleep, the constipation, the nausea. When you do those things well, everything falls in place.”—Dr. Halm
One treatment course to question, according to the American Society of Clinical Oncology’s Choosing Wisely list, is the use of cancer treatments at the end of life. The society recommends that patients with advanced, solid tumors be shifted to palliative care when previous treatments haven’t worked and no additional, evidence-based treatments are available; when patients can’t care for themselves and spend most of their time in a chair or a bed; and when they aren’t eligible for a clinical trial.
Dr. Lowell Schnipper, MD, who led the group that created the list, says this guidance can be helpful to hospitalists. He says hospitalists should be aware of the patient’s “trajectory” and should only call in consultants when “something clearly suggests that this situation is reversible.”
Dr. Suresh Ramalingam, MD says conferring with the oncologist before talking to a patient about hospice care is crucial, because new treatments are available that can bring about remarkable turnarounds, even in patients in dire condition.
“For certain subsets of patients with cancer, there are specific, molecularly targeted therapies that produce so-called ‘Lazarus responses,’ he explains. “They are bed-bound, totally crippled one day, and a few days after you give them the drug, they’re like a new person walking into your clinic.”
Dr. Josiah Halm, MD, says that, working at a comprehensive cancer center like M.D. Anderson Cancer Center in Houston, he sometimes sees patients who won’t accept the initial determination that aggressive treatment is not a good option when they have poor performance status. They sometimes still demand “small chemo,” or “a little chemo,” from their oncologist.
“Sometimes these patients would have gone elsewhere. They’ve been told, ‘Look, what you need is hospice; there’s nothing else we can do.’ And they’ll come here,” he says. “Either we’re telling them the same thing and that’s when they accept it or [they are] still demanding treatment. Sometimes they may be eligible for cancer treatment after being reviewed by our oncologists.
“The best treatment, regardless of anything else, is really symptom control, palliative care, taking care of the anxiety, the pain, the sleep, the constipation, the nausea,” he adds. “When you do those things well, everything falls in place.”
Dr. Halm sometimes asks patients what he can do to make them feel better “today,” with emphasis on the moment. In this way, he gets patients to focus on one main symptom that is causing them the most discomfort.
When patients don’t want to accept palliative-only care, Dr. Gadiraju says, it’s helpful to get them to realize they are still getting treatment, even if the nature of the treatment is different.
“We don’t want the patient to ever feel like we’re giving up on them,” he says.