Gynecologic Oncologist Views Influencing Referral to Outpatient Specialty Palliative Care

Abstract

Objective Early specialty palliative care is underutilized for patients with advanced gynecologic malignancies. We sought to understand how gynecologic oncologists’ views influence outpatient specialty palliative care referral to help inform strategies for improvement. Methods/materials We conducted a qualitative interview study at six National Cancer Institute-designated cancer centers with well-established outpatient palliative care services. Between September 2015 and March 2016, 34 gynecologic oncologists participated in semi-structured telephone interviews focused on attitudes, experiences, and preferences related to outpatient specialty palliative care. A multidisciplinary team analyzed transcripts using constant comparative methods to inductively develop a coding framework. Through an iterative, analytic process codes were classified, grouped, and refined into themes. Results Mean participant age was 47 (SD 10) years. Mean interview length was 25 (SD 7) minutes. Three main themes emerged regarding how gynecologic oncologists view outpatient specialty palliative care: (1) long-term relationships with patients is a unique and defining aspect of gynecologic oncology that influences referral, (2) gynecologic oncologists value palliative care clinicians’ communication skills and third-party perspective to increase prognostic awareness and help negotiate differences between patient preferences and physician recommendation, and (3) gynecologic oncologists prefer specialty palliative care services embedded within gynecologic oncology clinics. Conclusions Gynecologic oncologists value longitudinal relationships with patients and utilize specialty palliative care to negotiate conflict surrounding prognostic awareness or the treatment plan. Embedding specialty palliative care within gynecologic oncology clinics may promote communication between clinicians and facilitate gynecologic oncologist involvement throughout the illness course.

How views of oncologists and haematologists impacts palliative care referral: a systematic review

“…Prefer concurrent model over sequential model. Barriers to referral are, a. inadequate palliative care resources b. refusal by palliative care to take patients receiving anti-cancer therapy c. lack of clear guidelines regarding timing of referral 33 Hay et al (2017) [ 42 ] USA What are the Gynaec-oncologist’s views that influences the utilisation of outpatient specialist palliative care? 34 Gynaec-oncologists working at NCI designated cancer centres Grounded theory Long term relationship with the patients helps in convincing the patients to access palliative care.…”

“…Inability to handle emotional reactions associated with palliative care referral (Horlait, 2016 [ 36 ]) Self-efficacy Symptom management, psychosocial support and communication is integral part of oncology and can provide ourselves (Schenker, 2014 [ 46 ]) (LeBlanc, 2015 [ 47 ]) (Feld, 2019 [ 55 ]) (Sarradon-Eck, 2019 [ 58 ]) Oncologists have training in managing physical and psychological symptoms, and communicating with patients and families (Cherny, 2013 [ 38 ]) (Johnson, 2008 [ 40 ]) (Ward, 2009 [ 41 ]) 2. Power relationships and trust issues Control and coordinate the care process Be responsible for the care of the patient till the end (Horlait, 2016 [ 36 ]) (Schenker, 2014 [ 46 ]) (Rhondali, 2013 [ 45 ]) (Hay, 2017 [ 42 ]) Coordinate the care of the patient at all stages of the illness (Cherny, 2013 [ 38 ]) (Wright, 2017 [ 43 ]) Referral leads to loss of control (Hay, 2017 [ 42 ]) (LeBlanc, 2015 [ 47 ]) Dislikes interference in patient care (Schenker, 2014 [ 46 ]) (Rhondali, 2013 [ 45 ]). Gatekeeping Wait till the end of potential curative treatment to make referral (NyirÖ et, 2018 [ 53 ]) Referral only when all the treatment is discontinued (Prodhomme, 2018 [ 56 ]) (Sarradon-Eck, 2019 [ 58 ]) Initiate palliative care discussion only when there is an explicit request (Prodhomme, 2018 [ 56 ]) Competency based trust Treatment provided by palliative care not as expected (Morikawa, 2016 [ 39 ]) Palliative care providers not skilled in managing side effects (Morikawa, 2016 [ 39 ]) Unable to differentiate a recoverable sick patient from a dying patient (Gidwani, 2017 [ 51 ]) Do not have adequate oncology knowledge to counsel patients (Cherny 2003 [ 38 ]) Lack aggressive approach (Morikawa, 2016 [ 39 ]), (Schenker, 2014 [ 46 ]).…”

“…Making a palliative care referral: A daunting task Stigma associated with palliative care Palliative care referral equals death, end of life, terminal care (Morikawa, 2016 [ 39 ]) (NyirÖ et, 2018 [ 53 ]) (LeBlanc, 2015 [ 47 ]) (Horlait, 2016 [ 36 ]) (Cripe, 2019 [ 52 ]) Negative perception about palliative care precludes the use of the term (Horlait, 2016 [ 36 ]) (NyirÖ et, 2018 [ 53 ]) (Tricou, 2019 [ 57 ]) (Sarradon-Eck, 2019 [ 58 ]) (Wentlandt, 2012 [ 48 ]) (Wentlandt, 2014 [ 49 ]) The term palliative care is unsuitable, scares people, harms them. (Sarradon-Eck, 2019 [ 58 ]) Elicits feelings of abandonment, stopping treatment and euthanasia (Sarradon-Eck, 2019 [ 58 ]) Use supportive care and comfort care instead (NyirÖ et, 2018 [ 53 ]) (Sarradon-Eck, 2019 [ 58 ]) Reluctance to discuss death and dying (Prodhomme, 2018 [ 56 ]) Discussing death is stressful and a taboo (Prodhomme, 2018 [ 56 ]) (Horlait, 2016 [ 36 ]) (NyirÖ et, 2018 [ 53 ]) Patients and families get alarmed by mention of palliative care (Smith, 2012 [ 44 ]) Physicians have to address the negative connotation associated with palliative care (Hay, 2017 [ 42 ]) Palliative care referral requires careful explanation (Wright, 2017 [ 43 ]) Referring to palliative care means patients are weak and unable to fight the disease (Rhondali, 2013 [ 45 ]) Illness and treatment related factors Advanced, recurrent or metastatic cancers are referred (Rhondali, 2013 [ 45 ]) Unpredictable course of illness hinders referral (Morikawa, 2016 [ 39 ]) Relapsing and remitting nature of haematological malignancies is a barrier for referral (Wright, 2017 [ 43 ]) Rapid progression and complications hinder referral (Wright, 2017 [ 43 ]) Short time frame from onset of symptoms to end of life is a constraint for referral (Tricou, 2019 [ 57 ]) Prognostic uncertainty is a barrier (Ethier, 2018 [ 54 ]) Refer...…”

Pattern and Predictors of Outpatient Palliative Care Referral Among Thoracic Medical Oncologists

“…To date, a majority of palliative care referrals are initiated based on oncology teams’ clinical judgement instead of automatic referrals based on standardized criteria . Several qualitative and quantitative studies have examined how the attitudes and beliefs of oncologists toward palliative care could affect their willingness to refer patients ; however, there is a paucity of literature on which oncologist characteristics and patient characteristics are associated with the actual volume of outpatient palliative care referral . A better understanding of which clinician and patient characteristics are associated with the volume of palliative care referral in the real‐world context may help to overcome the barriers to timely palliative care access.…”

Strategies for Introducing Outpatient Specialty Palliative Care in Gynecologic Oncology

“…This study was approved by the University of Pittsburgh Institutional Review Board (PRO15070206). Results from this study have been previously published 18 ; however, no prior analysis has examined the strategies gynecologic oncologists use to present palliative care to their patients.…”