As a rough rule, oncologists have limited postgraduate education in palliative care, and palliative care specialists (who may have postgraduate training varying from country to country) are not consistently required to have oncology training. As a consequence, misconceptions and differences in opinions as to what is defined as appropriate care for the individual patient may impede patient-centred care. Similarly, lack of knowledge and insight into oncology (the tumour-directed treatment) among palliative care specialists and lack of understanding of palliative and supportive care among oncologists may hinder optimal collaboration.
We propose that rotations to palliative care units or teams should be compulsory during oncology training, and that oncology rotations should be compulsory during palliative care training. Doctors trained in both oncology and palliative care (palliative oncologists) may serve as facilitators for optimal integrated care, advocating supportive and palliative care for their oncology colleagues and vice versa. Continued medical education in ‘palliative/supportive oncology’ – or indeed patientcentred care – for both specialties should be encouraged. Research in palliation provides oncologists with the opportunity of ‘evidence-based’ best practice and the cooperation between oncologists and palliative care specialists in common research projects should also be encouraged. An international common curriculum in palliative care training, describing mandatory learning goals in essential features of palliative care, should be developed. Such a curriculum could include compulsory rotations in oncology.
Communication is essential for all clinicians and even more so for oncologists, who are often confronted with breaking bad news during consultations. Continuous training in communication skills must be provided. Appropriate communication skills promote patient-centred care, prognostic awareness and also lower a physician’s risk of burnout. In addition to breaking bad news, oncologists provide information on prognosis and treatment alternatives to the patient and their caregivers. Patients are expected to be actively involved in the decisions about their anticancer treatment (tumour-centred) and planning of care, how to optimise QoL, etc. (patient-centred care). This process of shared decision-making may often be conducted in collaboration between the oncologist, palliative care specialist, home care personnel and the family practitioner.
Systematic Assessments of Patient Symptoms, Needs, Interventions
During routine consultations, many symptoms are missed or unaddressed. Systematic symptom assessments using a set of standardised tools to ask the patient for his/her needs, symptoms, toxicities and current challenges in everyday life make doctors aware of symptoms and unmet needs otherwise not detected. A selected set of patient-reported outcome measures (PROMs) should be defined as a part of the standard patient assessment in any oncology and/or palliative care unit and utilised at regular intervals, the timing of which should be defined in standardised care pathways (see above). Rather than the traditional individual physician- dependent assessment and referral, this will increase the likelihood of referral and facilitate timely patient-centred interventions based on needs and not only on prognosis. The scores must be documented on demand in the patient’s records. Symptom scores above predefined levels should then always prompt interventions and/or referral to MDTs or palliative care specialists. Adequate, evidence-based interventions according to supportive/palliative care guidelines must follow such assessments, and the effects of the interventions implemented in response to the assessments must again be followed up and assessed systematically.
The financial resources allotted to palliative care research are usually low. The developments in tumour-directed treatment approaches lead to cancer being considered more as a chronic disease and give opportunity to incorporate supportive and palliative care research into oncology research programmes. National healthcare authorities must prioritise integrated research programmes and projects specifically. Research areas could be concentrated on three levels:
- System-oriented studies on the implementation of models of care, integration and how to implement evidence-based knowledge;
- Patient-oriented studies to examine symptoms, communication and decision-making; and
- Public health-oriented studies on the external validity of research findings and implementation strategies.