Why don't oncologists refer to palliative care?
And will their own society's strong recommendation ever change their minds?
"Should palliative care concurrent with oncology care be standard practice?
Answer: Yes, unequivocally.
And EARLY, within 8 weeks, not at the end of life."
—"Using the New ASCO Clinical Practice Guideline for Palliative Care” (2017)
“Oncology clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of the disease, alongside active treatment of their cancer.”
—Palliative Care for Patients With Cancer: ASCO Guideline Update, July 1 2024
Every day, patients with advanced metastatic cancer arrive in emergency departments and ICUs with the terrible complications that signal they are in the final days of their lives. Intensivists are used to managing respiratory failure, shock, sepsis, pulmonary embolism, acute kidney injury, and hemorrhages—sometimes simultaneously. But in people with advanced metastatic cancer, such major acute organ failure is rarely reversible. Death, for so long pushed into the realm of the unreal, the someday, suddenly looms at the door, here, now, refusing to be denied.
Intensivists and emergency physicians face these situations with dread. They know aggressive treatment at the end of life will likely produce and prolong suffering, without changing the outcome.
They must somehow stabilize the patient (who is often too ill or terrified to engage meaningfully), elucidate and communicate the complex medical situation, and initiate an end-of-life, goals-of-care conversation with a desperate patient and family, all amidst the stress and chaos of an ICU or ED. It’s impossible to do all these things well at once.
Naturally, difficult emotions arise, and a thought bubbles (or boils) into awareness:
Why didn’t their oncologist talk to them about this before?
Oncology Guidelines Strongly Advise EARLY Palliative Care Referrals in Advanced Cancer
In 2024, the American Society of Clinical Oncology (ASCO) published an evidence-based guideline update reaffirming its prior position: patients with advanced cancer should receive early palliative care because it leads to better outcomes.
(This publication has no association with any specialty society; follow the links in this post to read the specific guideline text.)
The ASCO guideline advises that patients with advanced cancer, seen either in hospitals or clinics, should receive dedicated palliative care as early as possible, to proceed concurrently along with active treatment for their cancer.
Referring to specialized palliative care early improves symptom management and increases the likelihood that a patient’s goals of care and spiritual needs will be met.
Concurrent palliative care should start promptly, and no later than 8 weeks after the diagnosis of advanced cancer (not as a final-hours transfer to hospice when death is imminent).
ASCO:
“Do not wait to refer all patients with advanced cancer to an interdisciplinary palliative care team until the end of life.”
The guideline applies to all patients with advanced cancer, with evidence being greatest for metastatic solid cancers (prostate, breast, lung, colon, etc).
This was a strong recommendation, based on moderate-strength evidence.
ASCO is the most influential U.S. oncology specialty society; its focus includes all cancer, but especially solid cancers.
The American Society of Hematology (ASH) focuses primarily on blood disorders and cancers, including lymphoma and leukemia. Although not in a formal guideline, ASH representatives have also recommended early palliative care for patients with aggressive lymphomas or other hematologic malignancies.
Early Palliative Care Can Improve and Extend Life in Advanced Cancer
The ASCO guideline comes in response to abundant, consistent evidence that early palliative care referrals result in better outcomes for patients.
In a dozen randomized controlled trials, patients with advanced cancer who were referred to palliative care early had improved quality of life, and often lived longer than patients receiving standard care, which frequently included excessive and harmful chemotherapy and hospitalizations at the end of life.
A 2022 meta-analysis of 12 randomized trials also concluded that early palliative care in advanced cancer improved quality of life and reduced symptom intensity. The effects were strongest when palliative care was initiated more than three months before death.
Most Oncologists Do Not Refer to Palliative Care At All
Few oncologists refer advanced cancer patients to palliative care early. In a surveyed sample cited by ASCO, no oncologists did so—zero. Two-thirds of responding oncologists (68%) said they never refer their patients to palliative care at all, while one-third (32%) referred to hospice only in the expected last month of life.
Palliative care referrals and integration of their services into cancer care are much more common at large, urban, highly-resourced cancer centers.
And it’s true there’s a shortage of palliative care physicians and advanced practice nurses, making immediate universal implementation of the guideline impossible.
But that’s not the primary obstacle. There seems to be a deeper, more fundamental, philosophical opposition to palliative care among oncologists.
For example, in another survey, oncologists reported aversion or skepticism toward palliative care, but one-third of them said they would consider referring if it were termed “supportive care.” (This rebranding is indeed underway at many palliative care programs.)
A qualitative analysis of 23 studies of thousands of oncologists’ attitudes worldwide found themes of distrust of palliative care practitioners’ competency; a preference by oncologists to control care; excessive burdens created by incorporating palliative care referrals into a practice, and concerns that care would be terminated early against the oncologist’s advice.
Overcoming such deeply entrenched beliefs and disincentives won’t happen easily. But the evidence of benefits to patients is clear, and so is the guidance from oncologists’ largest U.S. specialty societies.
What would it take for most oncologists to start referring patients with advanced cancer to palliative care early—or at all?
References
Sanders JJ et al. Palliative Care for Patients With Cancer: ASCO Guideline Update - Jul 1 2024
ASCO Slide Deck on the 2024 Guideline Update
Supportive Care and Treatment Related Issues | ASCO
Oreofe O. Odejide. Strategies for introducing palliative care in the management of relapsed or refractory aggressive lymphomas. American Society of Hematology education program, 2020
Salins et al. How views of oncologists and haematologists impacts palliative care referral: a systematic review | BMC Palliative Care 2020
This is an absolute travesty. Can’t tell you how many times I have had goals of care conversations with my critically ill patients’ families when they come to the ICU. This needs to change. This has inspired a future podcast episode to further raise awareness and advocate. Thank you!
Great! Thanks again. This one would be curious to know if seen in other countries.
Recently had a 92yo stage iv duodenal cancer - more liver mets than actual Mets players - who had a nice 4d icu stay for sbo and aspiration pneumonia - the private oncology practice (run by private equity who have billboards and private transport vehicles for their monopolistic supply chain) told him - you have 3-6months no chemo 1yr chemo. Well the pt’s a living - +amio for his afib worsening, +ngt for 4d as exasperated surgeons really didn’t want to operate, and plus some good ol abx for that aspiration pneumonia. To be fair he seemed like a mentally strong 92 but still - no statistics allow such a statement to be offered precisely and you need to be clearer about side effects.
Would like that decision to occur independent of the numerous downstream financial incentives such a practice has.
No palliative care trigger.
Like you are giving “palliative” chemo but not requesting actual palliative care?!
*who knows how intensivists will be if/once we or ones close to us get there? In my small n of docs who go through similar - (again selecting for ones seen in the icu) it’s not a minor amount that will defer futile care and opt for onc aggressiveness.