With palliative physicians, treatment options never run out

February 18, 2019 | by Malcolm Bedell

Purvi Patel, M.D. - Profile Photo Purvi Patel, M.D., assistant clinical professor in the Department of Supportive Care Medicine
This is the second in a series of articles about palliative care.
 
As a cancer patient, your care team may include a range of specialists, each devoted to a specific area of treatment.
 
But unlike medical oncologists, who may be focused on using chemotherapy, radiation or surgical solutions to treat cancer, or psychiatrists, who may be concentrating primarily on mental issues including stress and anxiety, palliative care physicians provide care for the “whole patient.”
 
“Many of the members of the cancer care team need to be focused on the disease itself,” said Purvi Patel, M.D., assistant clinical professor in the Department of Supportive Care Medicine at City of Hope. Palliative-care physicians take more of a holistic approach, more patient-focused. We speak with patients and families to find out what matters most to them, and together, we figure out how to incorporate those goals into their treatment plan.”

Balancing Treatment With Quality-of-Life Goals

As part of an overall course of treatment, many physicians are trained to look forward to the next possible step, including available chemotherapy, radiation or surgical options, without always fully considering the impacts these choices can make on a patient’s overall quality of life. Palliative care physicians help patients take a step back from the rigors of treatment to examine lifestyle goals.
 
“When we ask a patient what they are expecting from the next round of treatment,” said Patel, “They will often explain, ‘I’m tired of being tired,’ or ‘I’m tired of missing family events, and even if this chemotherapy could potentially help me live longer, I don’t want to spend that time in the hospital.’” Palliative care physicians help patients make choices that align with their quality-of-life goals, instead of strictly their physical cancer treatment goals.

When Treatment Stalls, Palliative Care Physicians Can Provide Reassurance

Patients may not always be willing to make these quality-of-life sacrifices when considering the next stage of treatment. “Sometimes, a patient may express feelings of ‘failing’ their hematologist or oncologist if they’re choosing not to go through with the treatment that’s being offered,” said Patel. “Other patients may be willing to spend every day in the hospital, as long as there are more treatment options available.”
 
This is where palliative care physicians can help patients evaluate their treatment goals in order to make the best possible decisions for their care, without being preoccupied with the sense that they might somehow be disappointing their primary doctors.

Palliative Care Physicians Evaluate the Whole Patient

During cancer treatment, the potential for suffering isn’t just limited to physical pain or illness. There is an emotional and spiritual component to care as well, and this is where palliative care physicians play an important role. “We improve quality of life in any or all of these aspects,” explained Patel. “There may be physical suffering, but there is also existential distress, or emotional suffering, and those are areas where we try to identify issues.”
 
Palliative care physicians often become the lead in a care team that also includes chaplains, psychiatrists and pain management specialists, offering overall assessments, recommendations and referrals to other specialized members of the team. “It’s our job to identify specific areas of need,” said Patel, “and then call in other members of the team when extra support is warranted.”

Pain Management Is a Key Component of Palliative Care

“Seventy percent of patients diagnosed with cancer have some amount of pain, at some point,” explained Patel. Sometimes, this pain can become so crippling that patients aren’t able to focus on any other aspect of their care, which makes effective pain management critical. Because pain pathways and the medications used to treat them can be complex, palliative care physicians receive unique training in pain management.
 
For many patients, pain and neuropathy can become so debilitating that they may choose to stop maintenance chemotherapy. When a patient chooses to stop potentially life-extending treatment due to side effects, that presents a great opportunity for us to treat the specific side effects and enable the patient to continue treatment,” Patel said.

For Palliative Physicians, There Are Always More Options

With certain aggressive or rapidly advancing cancers, some specialists reach the limit of care they are able to provide for their patient, after all treatment options have been exhausted. This isn’t the case for palliative care physicians, for whom there are always more treatment options and ways to improve a patient’s quality of life.
 
“Palliative medicine is one of the few fields where there’s always something we can do,” explained Patel. “An oncologist may eventually have to explain to a patient that there are no more treatment options, no potential for a transplant or no more clinical trials. In our field, there is always something we can do. We may not be able to always save a patient’s life, but there is always something that a patient may be in need of that we can help with. This may include social issues, spiritual issues or family issues that may not change a patient’s outcome, but that can make the journey easier for everyone involved. Even when there may be nothing more we can do medically, we can still make a difference in the lives of both the patient and the people surrounding them.”
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