Understanding the Role of Palliative Care in Cancer Treatment

Muhammad Siddiqui, MD

Palliative care physicians work to improve the quality-of-life of patients with serious or life-threatening diseases, including cancer. Oncologists can work together with palliative care physicians to treat not only a patient’s disease, but also manage their emotional, spiritual, and practical needs.

“During the time when you notice the declining performance status, have those goal of care discussions, what patients want, so we can respect that. I think that would give the best quality-of-life for them and their families,” said Muhammad Siddiqui, MD, in an interview with Targeted Oncology^TM.

In this interview, Siddiqui, department of palliative medicine, Virginia Cancer Specialists, went more in-depth about the role palliative medicine can play in cancer care and how palliative care physicians and oncologists can work together in patients’ best interests.

Targeted Oncology: How do you work closely with the palliative care professionals in your practice?

Siddiqui: We’re pretty lucky we have 2 palliative care providers, physicians who are part of the practice: me and Jessica Heintz, MD, FAAHPM. We also have a team approach to care. We just hired our third social worker; we have 3 social workers who are part of the team. We also have a dietician, who is really helpful for our patients. We work a lot with the hospital-based palliative care team too, which also has chaplain services available.

In our practice, it doesn't even have to be just the doctors that refer our patients to palliative care services. Honestly, it could be anyone on the whole oncology team. The infusion nurses, they’re on the frontline, and they're seeing the patients and how they're doing on a day-to-day basis. They’ll actually alert the team and our nurse navigators who work with our oncologists in place of palliative care referral. Everyone keeps an eye out for the patients. It can help [patients] with [their] symptoms and try to attain that best quality-of-life, especially when they're on treatments.

What are the key goals when addressing pain for a patient with cancer at the end of their life?

I always tell patients, especially when we're at that point, that we try to manage their pain the best we can. Especially during end-of-life, it can be excruciating pain at times. I always tell the patients I want to come up with a plan that still gives you the best pain relief, but not just ratcheting up pain medicines. Patients just don't want to sleep all day; they want that time to be able to spend with their family and enjoy those moments.

Whenever I have a patient who's in intractable pain, I always tell them this: I'm going to do the best I can, and we probably will have to make changes. Just because I start X, Y, and Z today for your pain, this doesn't necessarily mean that that's what it's going to be. Especially for those patients who are end-of-life, I usually follow-up with them within 48 hours. Even the next day, I'll have them email my nurse navigators. They'll have the phone numbers, too.

I set realistic expectations with them, letting them know that we may not solve everything today, but let's work on it over the next couple of days where we can get your pain better, but you still have the energy and that desire to still speak with your family and do those things that you want to do for the for the best quality of life and the best pain relief.

What are your recommendations on the frequency of visits and what to look for during that time?

I usually have folks at that stage usually follow-up with me once a week, or if not, every 2 weeks, just to see how they're doing. Nowadays, I think having telemedicine as our new resource ever since COVID has been a blessing for our patients. Some of our patients who are still on treatment but are toward more of the later stages of cancer can still have access to care. I think before telemedicine, a lot of times they would maybe not have the energy or the strength to come to the office. Now we can still provide the care to them.

What I'm looking for is how well are they eating? How well are they performing their [activities of daily living]—cleaning, taking care of themselves? When those things start to deteriorate in the setting of late stages of cancer, and losing weight, that’s a big prognostic indicator. I think that should be a red flag to our team, to the oncologist, to us palliative care providers for the patient’s decline. This is the time—before there's a major emergency—where I usually like to have those conversations with the patients and families. It helps us prevent admissions, if we can have those conversations too, and do symptomatic treatment before there's an emergency.

What research related to palliative care have you seen recently that you would recommend to other oncologists?

I've seen probably 3 or 4 recent articles published in the last 2 to 3 years and all with a similar theme. There is a kind of a new term to say called supportive oncology. In supportive oncology, that includes having a palliative care team integrated actually within the oncology practice.

I think a lot of times, even now, unfortunately patients, when they see palliative care, still think of hospice. I think before in the older way things were done is that palliative care providers would really get called in within maybe the last couple of weeks. So, a lot of patients would associate it with hospice. The new model that research is showing is that if you can get palliative care more involved earlier, when patients are first being diagnosed with serious illness, not only does it provide better quality of life, but better patient satisfaction. There are studies now to show that it increases life [expectancy]. Patients live longer when they’re feeling more comfortable and having a better quality of life.

What key advice do you have for other oncologists on having these palliative care or end-of-life discussions with patients?

Whenever I see patients, we always intervene on an initial visit. We'll talk about something called advanced care directives, advanced care planning, and living wills, and so forth. I think the big message is I'd like to give my oncology and oncologist colleagues is that when we see that really that major decline in performance status, that when folks aren't doing well—the rapid losing weight, maybe their symptoms are getting worse—that's when we really need to have more upfront goals of care discussions. I think if the oncologist folks make sure that, if somebody is approaching the end-of-life, to have a plan in there, so the family isn’t in a state of emergency, just rushing to the ER. Have a plan with symptoms, have a plan with pain management, anxiety, nausea, to the different symptoms. Also address the patient's well-being—kind of a holistic picture. I think that's what patients are looking for during that time. Not just the physical comfort with medicines and symptom management, but also emotional support.

It’s always good to have conversations earlier. But when folks are declining, I usually word it in the nicest way that I can. As a palliative care provider, a goal of mine is to always try to have this be as easy [as possible] on the family and to not have to make very difficult decisions. I usually tell families that maybe we can avoid this and have difficult conversations beforehand.