What Do We Mean by Integration?
The term ‘early integration’ facilitates a departure from the common belief that palliative care is only about end-of-life care or only to be provided when anticancer treatment is no longer an option. However, palliative care should not be dichotomised as ‘early’ or ‘late’ – its introduction must be timely and needs-based. Integration in healthcare can be seen as a process designed to overcome the various barriers obstructing delivery of optimal care. These barriers may exist on multiple levels – organisational, financial, professional and/or personal. In cancer treatment, many medical professions are involved, and coordination of timely and appropriate interventions is critical for the optimal treatment outcome. This patient-centred care (including both supportive and palliative care) should be integrated using a multidisciplinary approach for discussions about the best possible treatment for the individual patient throughout the continuum of care – from primary diagnosis to end-of-life care. The patient-centred focus is just as important for patients who are at follow-up after curative treatment. The benefits of coordinating medical specialists in MDTs coming from radiology, pathology, surgery, medical oncology and radiotherapy are no longer questioned.
Integration of anticancer- and patient-directed interventions are proposed as an effort to bridge the gap between oncology and palliative and supportive care. In the presence of metastatic disease, surgery, anticancer agents and radiotherapy are, with some exceptions, delivered with the goal to prolong life and/or to treat symptoms. It may be called palliative treatment by oncologists, but the majority of people associate palliative
care with end-of-life care. Therefore, ‘supportive care’ has been suggested by some experts as a term for any patient-directed measures taken to optimise patient care in earlier phases of the disease, in an effort to lower the threshold for referral, both for oncologists and patients. While definitions are important but also arguable, efforts must be focused on alleviating patients’ physical, psychological, social and existential concerns in all stages of disease, from survivorship to end of life.
New developments in anticancer treatments have prolonged life expectancy for many patients, redefining cancer as a chronic illness. This implies that living with cancer rather than dying from cancer has become a more frequent challenge in oncology care. Living with cancer is a new dimension and challenge for most patients and their caregivers. As mentioned earlier, ‘to live as long and as well as possible’ is the ambitious goal for most patients. It means that healthcare can contribute somewhat, but the lives are lived by each person in their home environment. A balance should be reached between our effort to prolong life, relieve symptoms, improve functions and support patients and their caregivers to live their lives.
How to guide and support the optimal life for patients and caregivers is a ‘complex intervention’ that requires the competence of different healthcare providers. This benefit should be made visible, understandable and balanced for each individual. As mentioned earlier, an MDT approach is needed, therefore supportive and palliative care is always teamwork. The team must also be balanced with the right contribution from the oncologists, and the patients and their caregivers should be considered as members of the MDTs.
Clinical resources, both community-based and in hospitals, are limited. This must be reflected to ensure a level of care appropriate to the complexity of indicated interventions. Structured systematic cooperation between different specialities and between different levels of care may ensure continuity of care when shifting between hospital departments and between hospital-based and community-based settings. Early referrals to palliative care consultations may be obstructed by limited palliative resources. Different levels of palliative care based on complexity must therefore be outlined, where hospital and primary care/family medicine specialists also work together. Most patients wish to remain at home as much as possible and for as long as possible, and (some) will die at home. In the home environment, families can live and act differently than in most institutions. Well-functioning, community-based care
is crucial to achieve this. If the conditions of the patient worsen and specialist care is needed, early access will facilitate better home care and patient care in general. A dynamic organisation is needed where primary care/family medicine specialists and homecare nurses collaborate in an integrated way with specialist oncological and palliative care.
Randomised studies on integration of oncology and palliative care in various cancers were summarised in the 2018 Lancet Oncology Commission article (Kaasa et al). Although different designs and endpoints were used, the studies consistently found that integrated care improved survival and symptom control, and led to less anxiety and depression, reduced use of futile chemotherapy at the end of life, and improved family satisfaction, QoL and use of healthcare resources. So, how can we achieve integration?
To facilitate integration, steps must be taken in several areas, including, but not limited to, the following: organisational infrastructures, education, communication skills, systematic assessments of patients’ symptoms and needs (including systematic follow-up of the palliative care interventions implemented in response to the assessment) and research.