Revolutionizing Palliative Care Delivery and Access to Improve Outcomes for Patients and Caregivers
Key Findings
- Clinician-researchers at Massachusetts General Hospital are addressing limitations in palliative care resources by developing and advocating for novel delivery methods
- They developed a personalized approach that tailors the timing of palliative care visits to patients' clinical needs
- Virtual methods of palliative care resulted in patient- and caregiver-reported quality of life scores equivalent to those derived from in-person care
Clinician-researchers at Massachusetts General Hospital are driving a paradigm shift in the effective delivery of palliative care for patients with advanced cancer. Although modern medicine allows people to live longer with serious and complex illnesses, this introduces challenges to maximizing the benefits for all involved.
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"Evidence over the previous two decades demonstrates the efficacy of palliative care to improve outcomes for patients and families living with advanced cancers," says Joseph Greer, PhD, co-director of the Cancer Outcomes Research and Education (CORE) Program at the Mass General Cancer Center. "Although these services clearly benefit both clinical programs and those they serve, there remain obstacles in matching available resources to patient and caregiver needs."
Providing Support for Those Suffering
Palliative care describes an interdisciplinary approach to managing and providing relief from the symptoms and stress associated with an advanced illness. This approach optimizes support for the physical and psychological needs of patients and caregivers to improve their quality of life (QOL). Its success relies upon the collaboration of a team of clinical specialists to:
- Communicate expectations about the therapeutic roadmap and potential outcomes of treating an advanced disease
- Navigate the complex physical and emotional symptoms accompanying both the diagnosis and treatment of the illness
- Coordinate a comprehensive approach to care delivery in various settings
Clinical trials consistently support the ability of palliative care to improve outcomes for patients, their families, and the hospitals providing the care. Dr. Greer and Jennifer Temel, MD, clinical director of thoracic oncology and co-director of the CORE Program at the Mass General Cancer Center, have been at the forefront of this research for nearly two decades. They were the first to show the benefits of integrating palliative and oncology care for patients soon after diagnosis. This approach not only improved patient QOL and mood but also prolonged survival by 2.7 months.
"Research by our group and others dramatically shifted how palliative care is integrated into oncology settings. Moving it substantially upstream in the patient's illness course maximizes its impact on their well-being," says Dr. Temel. "We're now trying to address practical challenges to translating an ever-growing foundation of evidence into scalable delivery models to increase access to palliative care for patients and their families."
These challenges include a shortage of clinicians trained in palliative care specialties and a continued reliance on a referral-based model of care. Dr. Greer explains that subjectivity in decisions regarding palliative care can limit patient access to this type of support, especially in the critical early stages following a diagnosis.
Advances in the variety and efficacy of cancer therapeutics have also shifted how palliative care is delivered and for how long. High degrees of variability in patient responses to novel therapies, including the possible onset of significant side effects, present a range of issues. Dr. Temel adds that most advanced solid or metastatic tumors still represent incurable diseases. Therefore, people living longer and doing better may continue to struggle with having to live with a life-threatening illness.
"For most patients with cancer, we are unable to predict who will respond to a particular cancer treatment and for how long," explains Dr. Temel. "This uncertainty about the future can understandably cause significant distress for patients and their family."
A Novel Approach to Compassionate Care
Prior to the COVID-19 pandemic, Drs. Temel and Greer began a prospective, randomized clinical trial to evaluate a stepped versus standard approach to delivering early palliative care. Both methods initiated care within 12 weeks of diagnosis of advanced lung cancer. The patients receiving standard palliative care saw a palliative care specialist every four weeks, whereas the stepped approach tailored palliative care visits to patients' clinical needs.
Dr. Temel describes stepped care as a patient-centered model of support in which patients are only scheduled to meet with specialty clinicians when needed. Contact can be "stepped up" appropriately for patients needing increased clinical interaction. This approach addresses limited care resources while allowing patients to receive the care they need when they need it.
"Early integration of palliative and oncology care establishes rapport between the care team, patients, and their families," Dr. Temel explains. "This is essential to enable patients and the care team to build the relationship and trust needed to provide the best possible care for the patient."
Outcomes of the nearly five-year trial (February 2018 to December 2022) revealed that the stepped-care model was non-inferior to standard approaches in terms of patient-reported QOL. Notably, this was accompanied by fewer palliative care visits at 24 and 48 weeks post enrollment by patients in the stepped-care group (mean number of visits: 2.4 versus 4.7 and 3.8 versus 7.7, respectively).
The findings ultimately demonstrated the stepped-care model as an effective approach to providing palliative care according to patients' clinical needs.
Leveraging Technology to Increase Access
The pandemic also necessitated the use of telehealth as part of the trial protocol, which added another important dimension to the study's outcomes: The similar results between groups were attained while delivering some of the care via video visits.
A separate large-scale clinical trial (1,250 patients and 548 caregivers) compared the effectiveness of early palliative care delivered either by video or in-person visits. Over the course of 48 weeks, patients and their caregivers completed self-reported measures that included QOL, satisfaction with care and mood symptoms.
Results presented by Dr. Greer at the 2024 American Society of Clinical Oncology annual meeting demonstrated equivalent effects on patient-reported QOL. Patients and caregivers also similarly reported no differences in their mood symptoms or satisfaction with care between the method used for its delivery.
"These finding have implications for significantly improving access to early integrative palliative care," Dr. Greer explains. "This is particularly impactful for patients living far from clinics or confronted with physical ailments that make travel very challenging."
Shaping the Future of Palliative Care
Dr. Temel acknowledges Mass General's collaborative research and clinical care ecosystem as essential to driving change in a field comprised of individual specialists. As co-founders of the CORE Program, she and Dr. Greer oversee a transdisciplinary, multidimensional team that is rapidly transforming how palliative care is administered.
In line with this goal, they underscore the importance of their findings in the telehealth study and its broader implications for healthcare access.
"Clinicians, patients, and caregivers are advocating for legislative change targeting continued financial support of telehealth care," says Dr. Temel.
Legislation that expanded insurance coverage and reimbursement for these services during the pandemic is set to expire at the end of 2024. Therefore, providing evidence of telehealth's broad and significant clinical impact is critical.
"Our hope is that these results might inform policy decisions to support continued access to telehealth services," says Dr. Greer. "The utility of this approach for delivering high-quality care to patients with advanced cancer offers powerful evidence of its worth."
Learn more about the Cancer Outcomes Research and Education Program