Oncology Clinicians’ Challenges to Providing Palliative Cancer Care—A Theoretical Domains Framework, Pan-Cancer System Survey

Abstract

Despite the known benefits, healthcare systems struggle to provide early, integrated palliative care (PC) for advanced cancer patients. Understanding the barriers to providing PC from the perspective of oncology clinicians is an important first step in improving care. A 33-item online survey was emailed to all oncology clinicians working with all cancer types in Alberta, Canada, from November 2017 to January 2018. Questions were informed by Michie’s Theoretical Domains Framework and Behaviour Change Wheel (BCW) and queried (a) PC provision in oncology clinics, (b) specialist PC consultation referrals, and (c) working with PC consultants and home care. Respondents (n = 263) were nurses (41%), physicians (25%), and allied healthcare professionals (18%). Barriers most frequently identified were “clinicians’ limited time/competing priorities” (64%), “patients’ negative perceptions of PC” (63%), and clinicians’ capability to manage patients’ social issues (63%). These factors mapped to all three BCW domains: motivation, opportunity, and capability. In contrast, the least frequently identified barriers were clinician motivation and perceived PC benefits. Oncology clinicians’ perceptions of barriers to early PC were comparable across tumour types and specialties but varied by professional role. The main challenges to early integrated PC include all three BCW domains. Notably, motivation is not a barrier for oncology clinicians; however, opportunity and capability barriers were identified. Multifaceted interventions using these findings have been developed, such as tip sheets to enhance capability, reframing PC with patients, and earlier specialist PC nursing access, to enhance clinicians’ use of and patients’ benefits from an early PC approach.

Acceptability of automatic referrals to supportive and palliative care by patients living with advanced lung cancer: qualitative interviews and a co-design process

“…However, late referrals remain all too common, for a multitude of reasons [ 8 , 9 ]. Oncology clinicians have many competing priorities to address in brief appointments, and they have limited time and physical space to evaluate and address their patients’ supportive and palliative care needs or have conversations with them about the benefits of using specialist services [ 10 ]. Additional barriers include stigma around the term ‘palliative care’ [ 2 , 5 , 11 , 12 ] and inconsistencies in clinician referrals due to varied education, experience, interest, and understanding of PC [ 13 , 14 ].…”

“…In our prior intervention study aimed at integrating PC with metastatic colorectal cancer management ( www.pacesproject.ca ), we were able to cue oncologists and increase the proportion of patients receiving timely, early referrals for supportive and palliative care by 17%; however, continued barriers (e.g. competing priorities) remained a challenge for sustaining earlier referrals [ 10 , 17 ]. Consequently, our oncology clinician partners asked, “Why can’t the palliative care team directly offer patients early supportive and palliative care referrals?”.…”

Development of a tool for palliative care needs assessment and intervention: mixed methods research at a Swiss tertiary oncology clinic

“…By helping practitioners to identify patients' palliative care needs, patient outcomes may be improved (19). Yet some oncology practitioners struggle with systematically assessing palliative issues as a part of routine care (20).…”

Tertiary Inpatient Palliative Care within Region-Wide Services: A Retrospective Examination of Psychosocial and Medical Demographics at Admissions

“…This is even true in countries like Canada, an international leader in the discipline and whose clinicians' report an understanding of palliative care's scope and comfort in referring. This disparity in knowledge, stated referral comfort, and practice might be attributable to various system-and provider-level factors [8][9][10][11][12].…”

“…The treatment goal is usually to discharge home or to hospice, depending on patients' preferred location. Only 1% of the overall population accessing palliative services uses the IPCU as their first palliative care service, indicating the highly specialized role of this service [8,19].…”