Barriers to providing palliative care to patients with advanced cancer: A province-wide survey of oncology clinicians’ perceptions.

Abstract

88 Background: Despite known benefits, cancer care systems struggle to provide early, integrated palliative care (PC). Previously, we identified barriers to providing early PC as perceived by gastrointestinal oncology clinicians in Alberta, Canada (top barrier: time/competing priorities). Here, we expand on the previous study to better understand barriers to early PC for clinicians working with all tumor groups across Alberta. Methods: A 33-item survey was emailed to oncology clinicians in Alberta between November 2017 - January 2018. Questions were informed by Michie’s Theoretical Domains Framework (TDF) and Behaviour Change Wheel (BCW) and queried (a) providing PC in oncology clinics, (b) referral to specialist PC consultation, and (c) working with PC consultants and homecare. Results: Respondents (n = 268) were nurses (42%), physicians (25%), and allied health professionals (20%). Barriers most frequently identified were "patients’ negative perceptions of PC” (68%), “my limited time/competing priorities” (66%), and "capability to manage patients’", social (65%) and spiritual (63%) concerns. These factors map to all three BCW domains: motivation, opportunity, and capability. In contrast, least frequently identified barriers were in clinician’s own motivation, e.g. perceived benefits of PC. There were few significant differences in response by tumor group or profession (χ2 test, responses coded: disagree [1-3], neutral [4], agree [5-7]). Most notably, tumor groups differed in their perception that “the criteria for PC services are too restrictive” (p = 0.003), while nurses and allied staff reported that patients’ negative perception of PC is a barrier more frequently than physicians (p = 0.003). Conclusions: Surveying across clinicians and tumor groups using Michie’s TDF/BCW revealed that the challenges to an early integrated PC approach include all three sources of behavior, though not equally for all clinicians. Determining this has allowed us to tailor multifaceted interventions, e.g. tip sheets to enhance capability, re-framing PC with patients, and earlier secondary PC nursing access, to enhance clinicians use and patients benefit from an early PC approach.

Managing understandings of palliative care as more than care immediately before death: Evidence from observational analysis of consultations

“…As in the previous fragment, the use of general references makes their claim possible but not necessarily relevant to this patient. 48,49 In this instance, the clinician contradicts a possible understanding of inpatient palliative care as only being provided immediately before death by explaining the use of this unit for people at 'various stages of their … palliative care journeys' (arrow 1, lines [8][9][10][11]. They also explain to the patient why active treatment in an inpatient setting is necessary (lines 14-18).…”

“…A clinicians' confidence in managing these conversations could be a barrier to early referral to palliative care 21–23 . Research suggests that referring clinicians are sometimes poorly equipped to manage patients' understandings of palliative care as more than care provided immediately before death 8–10 . By virtue of primary treating teams' existing relationships with patients, these clinicians are well positioned to help patients understand the range of reasons they are being referred to palliative care.…”

“… 7 Although these understandings may be consistent with the deteriorating and terminal phases of palliative care for chronic illnesses and cancer, they do not easily equate with the very long periods people can receive palliative care while their condition is stable. Evidence suggests that some referring clinicians may be insufficiently equipped to manage patients' understandings of palliative care as more than care provided immediately before death, 8 , 9 , 10 while some also hold these views. 11 , 12 As well, some government policies may reinforce these limited understandings of palliative care by placing eligibility for palliative care at the point when a patient's primary goals become comfort, 13 rather than coinciding with active or other life‐prolonging treatments.…”

Frequency, Timing, and Predictors of Palliative Care Consultation in Patients with Advanced Cancer at a Tertiary Cancer Center: Secondary Analysis of Routinely Collected Health Data

“…Another possibility is that attitudes toward palliative care may vary between teams of oncologists treating different cancer types and affect likelihood of referral. However, in a survey of 268 oncology clinicians caring for patients with all cancer types throughout the province of Alberta, less than 5% believed that referring patients to palliative care is of little benefit [22].…”

Perspectives of Hematology Oncology Clinicians about Integrating Palliative Care in Oncology

“…The purpose was to characterize the barriers to integration of early pc for oncology clinicians. Data collected were previously analyzed for the entire cohort of oncology clinicians by Watanabe et al 22 . The…”