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Initiating Palliative Care in Advanced Cancer Patients – when is the right time? An Oncologist’s opinion

Author: Dr Asim Jamal Shaikh, Consultant Medical Oncologist, Head of Medical Oncology Division, The Aga Khan University Hospital Nairobi, Kenya
17 October 2017

It’s almost a routine in a busy oncology clinic every day to attend to some of your advanced cancer patients. These visits might be quotidian to the oncologist’s work schedule, but are often quite uneasy from the patient’s standpoint.

This encounter entails discussions and questions like, Doc! How long do I have? How long is this chemotherapy going to take? Oh, how much do you think that would cost me?  Seriously do you think that’s worth trying? So doc what’s next for me now?

While many of our patients keep on doing well, some indeed for a very long time, we ultimately reach “that bridge” that needs to be crossed. So the general perception amongst the colleagues seems to be that, that’s the time when a palliative care team should also be called in (if you are lucky to have one). The general cancer care guidelines however [1] insist  to integrate palliative care as early on as possible,  and those of us who have had the chance to do so would readily agree the huge difference that takes place in patient’s general care and quality of life.  On top of our practice model, the challenge remains on how and when exactly to really bring palliative care onboard. I somehow I feel that the word Palliative care has seemingly become synonymous with “That’s end” mind set for the patient and physician alike.

As a medical oncologist, I believe we could possibly come up with a better way of defining the semantics of palliative care specially to our patients with advanced disease and find ways of its cost effective inclusion in holistic care plan very early on, so that not only do they spend their time in life with great quality but also cross the eventual bridge with dignity, comfort and gratitude.

1. Ferrell, B.R., et al., Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol, 2017. 35(1): p. 96-112.

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    Dr. Robert Carter

    One semantic approach to explaining what we do as palliative care providers at Kijabe Hospital is to tell the patient that we focus on relieving whatever may be bothering the patient while his/her other doctors are continuing to manage the disease process itself. I've never yet met a patient who refused to let us help control pain or other distressing symptoms! "We specialize in helping you to feel better" has proven effective and acceptable in our experience.

    20/10/2017 17:04:00

    Margie Venter

    Dear Dr Shaikh
    Thank you for bringing up this topic! I think the move to integrate palliative care into oncology is as exciting as new targeted therapies on the market (especially given that targeted therapies are often unavailable in our setting).
    I am an oncologist who has transitioned into the field of palliative care, hoping to be able to integrate with my colleagues early on. It is difficult for many reasons - old habits die hard, where do responsibilities and boundaries lie, some just forget until it's very late in the game.
    For those patients to whom we have been able to offer it timeously ie from the time of diagnosis, I believe all have benefited - the patient (and family), the oncologist and PC clinician.
    I have found that most people have never heard of the term 'palliative care' - the people who struggle with it are health care practitioners? When you think of it as 'an extra layer of support', I think it is very digestible? We try and make sure symptoms are well controlled, assist in making treatment decisions based on their goals and wishes and ensure that the other spheres of life be it social, psychological or spiritual are also addressed.
    This has been shown to be a high value intervention with good outcomes and low costs - one of the few places in medicine which is a win-win for all, patients, doctors and funders alike.
    Regards
    Margie

    19/10/2017 16:36:18

    Fawwad Karim

    Good informative article.

    19/10/2017 01:03:51


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