ASCO leader affirms hospice's role
Oncologists need to better utilize hospice
Robert J. Mayer, MD, immediate past president of the Alexandria, VA-based American Society of Clinical Oncology (ASCO), says that skill in managing end-of-life care for cancer patients is as much a part of being a skilled oncologist as treating fever in neutropenia. "That responsibility shouldn't be transferred, but there are times when I and other oncologists are very gratified to have the support of end-of-life specialists."
Mayer, a medical oncologist at Dana Farber Cancer Institute in Boston and professor of medicine at Harvard University, made improving end-of-life care a major priority for his recently completed tenure as president of the 11,000- member ASCO. He was instrumental in bringing together a 20-member expert panel, whose position statement, Cancer Care During the Last Phase of Life, was highlighted at ASCO's recent annual meeting in Los Angeles.
"I run a training program for medical oncology fellows. The thing I do most is to teach them how to take care of patients," he says to explain his emphasis on end-of-life care. "I said to myself, I could contribute to the society with a focus on genetic therapy, but others do that better. What I do best is take care of patients."
The problem oncologists face, Mayer observes, is that care at the end of life, or care focused on patients' emotional concerns, isn't yet routinely taught in medical schools, isn't included in medical textbooks, and isn't part of medical specialty certification exams. "Where have doctors learned to take care of people outside of the hospital? When patients are at home, there's always a disconnect," he says. "Doctors don't know how to utilize community resources, how to listen, how to bring families together. It's not the sort of thing you can teach in the lecture hall. Our surveys show that the oncology community learned how to do these things in an experiential manner."
ASCO's end-of-life statement, published in the May Journal of Clinical Oncology,1 was described as a "sea change" for the organization by Ezekiel Emanuel, MD, of the National Institutes of Health in Washington, DC. The statement emphasizes the need to overcome clinical and economic barriers to appropriate end-of-life care, and observes, "Approximately 50% of all cancer patients do not survive the disease, and scientific progress must not distract us from that penetrating reality."
The document also singles out hospice as "an excellent model" of end-of-life care, which needs to be more effectively utilized by oncologists. However, Mayer points out, "the hospice community at times can be overly rigid, and has focused solely on hospice in an isolated manner. For the patient, transitioning from active anti-cancer therapy to end-of-life care cannot be done abruptly," he explains. "Nothing in the care of patients is black and white. There are no 90 degree angles."
When hospices have strict policies on total parenteral nutrition, radiation, or chemotherapy, it's harder for patients and families to adjust and make the transition, says Mayer. "We need to build on the dialogue - we both need each other. We both need to focus on care of the patient rather than what is or isn't hospice. Patient inclusivity rather than patient exclusivity is what ought to guide hospices." Barriers, and perceived barriers, to hospice referral need to be lowered, while fiscal support for end-of-life care needs to be improved, he adds.
Reference
1. American Society of Clinical Oncology. Cancer care during the last phase of life. Journal of Clinical Oncology 1998; 16(5):1986-1996.
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