As we close out 2022, we offer knowledge and encouragement to oncology nurses to clarify gains, gaps, and guidelines in palliative care.
As we close out 2022, we offer knowledge and encouragement to oncology nurses to clarify gains, gaps, and guidelines in palliative care. Palliative care continues its slow integration as a standard component of comprehensive oncology care. In 1994, board certification in palliative care was established for nurses; as of 1996, physicians could be board certified (Center to Advance Palliative Care [CAPC], n.d.-b). Yet almost 30 years later, a persistent misunderstanding continues in the minds of the public and clinicians who believe palliative care and hospice care are the same thing. Although both specialties offer comprehensive supportive services, hospice care is an insurance benefit for individuals who have a life expectancy of six months or less. Palliative care offers supportive interventions during curative or maintenance treatment and is not time limited (CAPC, n.d.-a; National Consensus Project for Quality Palliative Care, 2018).
Among the gains related to palliative care are that larger healthcare centers and comprehensive cancer centers now include palliative care as an integral component of clinical oncology care delivery, despite having to fund palliative care services internally (CAPC, 2019a; Hui et al., 2020); more nurses manage patients receiving palliative care than do other professionals (Schoenherr et al., 2019); and some Medicaid programs now require provision of palliative care services (Teshale & Fox-Grage, 2022). Yet in most community healthcare systems, palliative care is not integrated in care delivery (CAPC, 2019b). Although published guidelines provide clear recommendations for palliative care consultation in oncology care, gaps in knowledge and practice remain, particularly in the southeastern United States and rural areas (CAPC, 2019a; National Comprehensive Cancer Network, 2022).
A 2022 PubMed® literature search revealed no published articles on nurse-initiated orders for palliative care consultation, highlighting a modifiable barrier for access to this specialized care. Another important issue is a deficit in the palliative care workforce. Nurses often experience moral distress when supportive services are not available because of lack of palliative care clinicians. Thus, nurses may be reluctant to offer palliative care and provide treatment to terminal patients, whose quality of remaining life could be improved with this type of consultation (Maffoni et al., 2019; Schoenherr et al., 2019).
A great advantage of palliative care is the interprofessional nature of the specialty, which provides a greater range of culturally congruent care to patients and families. There are anecdotal reports of culturally congruent models of palliative care delivery (Cain et al., 2018). However, culturally competent palliative care—evidence based, with established standards and accompanying interventions—is in its infancy (Pentaris & Thomsen, 2020).
To continue to build our knowledge base about palliative care, this December 2022 issue of the Clinical Journal of Oncology Nursing includes three articles that advance the foundation for palliative care in clinical oncology through the illness trajectory. In Spine et al. (2022), three expert oncology nurses apply their communication skills and experienced competencies to various clinical scenarios to initiate or continue palliative care– and end-of-life–focused conversations with patients and caregivers. Booker (2022) provides a clinical primer about radiation therapy to support palliative care. Finally, to address end-stage concerns, DeWolf and Cazeau (2022) provide a comprehensive update about medical aid in dying in the context of U.S. state laws and clinical care.
From the Oncology Nursing Society’s (2022) position statement on palliative care, oncology nurses have an ethical responsibility to acquire and use current knowledge and skills to deliver safe, quality palliative care. Currently, there are many free or low-cost training options for palliative care. Let us encourage each other to learn, grow, and support oncology palliative care through professional development. The three articles in this issue continue to build a palliative care foundation for clinical practice, further integrating palliative care as a standard component of comprehensive oncology care.
Caroline Etland, PhD, MSN, CNS, ACHPN®, is an associate professor and the Kaye M. Woltman and Melisa R. McGuire Palliative Care Fellow in the Hahn School of Nursing and Health Science at the University of San Diego in California; and Ellen Carr, PhD, RN, AOCN®, is the editor of the Clinical Journal of Oncology Nursing at the Oncology Nursing Society in Pittsburgh, PA. Etland can be reached at firstname.lastname@example.org, with copy to CJONEditor@ons.org.
Booker, R. (2022). Palliative radiation therapy: The role of radiation therapy in palliative and end-of-life care. Clinical Journal of Oncology Nursing, 26(6), 628–635. https://doi.org/10.1188/22.CJON.628-635
Cain, C.L., Surbone, A., Elk, R., & Kagawa-Singer, M. (2018). Culture and palliative care: Preferences, communication, meaning, and mutual decision making. Journal of Pain and Symptom Management, 55(5), 1408–1419. https://doi.org/10.1016/j.jpainsymman.2018.01.007
Center to Advance Palliative Care. (n.d.-a). About palliative care. https://www.capc.org/about/palliative-care
Center to Advance Palliative Care. (n.d.-b). Specialty palliative care certification. https://www.capc.org/jobs/palliative-care-certification
Center to Advance Palliative Care. (2019a). America’s care of serious illness: A state-by-state report card on access to palliative care in our nation’s hospitals. https://reportcard.capc.org/wp-content/uploads/2020/05/CAPC_State-by-St…
Center to Advance Palliative Care. (2019b). Mapping community palliative care: A snapshot. https://www.capc.org/documents/download/700
DeWolf, T., & Cazeau, N. (2022). Medical aid in dying: An overview of care and considerations for patients with cancer. Clinical Journal of Oncology Nursing, 26(6), 621–627. https://doi.org/10.1188/22.CJON.621-627
Hui, D., De La Rosa, A., Chen, J., Dibaj, S., Guay, M.D., Heung, Y., . . . Bruera, E. (2020). State of palliative care services at US cancer centers: An updated national survey. Cancer, 126(9), 2013–2023. https://doi.org/10.1002/cncr.32738
Maffoni, M., Argentero, P., Giorgi, I., Hynes, J., & Giardini, A. (2019). Healthcare professionals’ moral distress in adult palliative care: A systematic review. BMJ Supportive and Palliative Care, 9(3), 245–254. https://doi.org/10.1136/bmjspcare-2018-001674
National Comprehensive Cancer Network. (2022). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Palliative care [v.1.2022]. https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf
National Consensus Project for Quality Palliative Care. (2018). Clinical practice guidelines for quality palliative care (4th ed.). https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-N…
Oncology Nursing Society. (2022). Palliative care for people with cancer [Position statement]. https://www.ons.org/make-difference/ons-center-advocacy-and-health-poli…
Pentaris, P., & Thomsen, L.L. (2020). Cultural and religious diversity in hospice and palliative care: A qualitative cross-country comparative analysis of the challenges of health-care professionals. Omega, 81(4), 648–669. https://doi.org/10.1177/0030222818795282
Schoenherr, L.A., Bischoff, K.E., Marks, A.K., O’Riordan, D.L., & Pantilat, S.Z. (2019). Trends in hospital-based specialty palliative care in the United States from 2013 to 2017. JAMA Network Open, 2(12), e1917043. https://doi.org/10.1001/jamanetworkopen.2019.17043
Spine, K., Skwira-Brown, A., Schlifke, D., & Carr, E. (2022). Clinical oncology nurse best practices: Palliative care and end-of-life conversations. Clinical Journal of Oncology Nursing, 26(6), 612–620. https://doi.org/10.1188/22.CJON.612-620
Teshale, S., & Fox-Grage, W. (2022, August 19). Emerging state innovations in developing a Medicaid community-based palliative care benefit. National Academy for State Health Policy. https://www.nashp.org/emerging-state-innovations-in-developing-a-medica…