Patient-reported Outcome Instrument for Guiding Timing of Palliative Care Consultations

Clinical Expert Commentaries   published on July 26, 2017
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Stuart Goldberg, MD
Division of Leukemia
John Theurer Cancer Center
Hackensack University Medical Center
Associate Clinical Professor of Medicine
Rutgers New Jersey Medical School
Hackensack, New Jersey
Patient-reported Outcome Instrument for Guiding Timing of Palliative Care Consultations

Hi, I am Dr. Stuart Goldberg. I am the Chief Medical Officer of a data and analytics company known as COTA, and I am also a member of the Division of Leukemia at the John Theurer Cancer Center in Hackensack, New Jersey. One of the most difficult situations for physicians is when to have end-of-life care discussions with our patients with advanced cancer. We do not want to have it too early because then it will be seen as taking away hope, and we do not want to delay it too late when the patient is brought into the hospital and receives unwanted care that is very expensive. How do we find the right time to have that difficult discussion?

Well, over the last several years, our company has developed a seven-item Likert-score survey that can be easily administered to patients in the outpatient setting. It asks questions like: What is your performance status? Are you in pain? Do you feel that you are burden to your family or to your finances? Are you depressed? From these seven non-threatening questions, we can give that information back to the physician. If one item is out, well, then you may want to get the social worker in or the psychiatrist or the financial counselor. What we saw was as all of the items started to fall apart, as the score in that survey got worse, we saw that patient survival actually went down significantly. At this year’s ASCO meeting, we are presenting that patients with a score of 28 (the survey goes from 0 to 112), we saw a significant drop in both 6 month and 12-month survival. This tells us that this might be an optimal time to have that end-of-life care discussion, and the patient is giving you permission, because they are telling you that they are distressed. We flipped around the traditional paradigm with the doctors now no longer saying the patient is doing poorly, let's have that discussion, but rather the patient is telling us, "I am not feeling well, I am very distressed." Now, the doctor can come in and say "I can deal with that distress, I want to help you through this," and maybe the answer is a palliative care consult or an end-of-life care consult. Or, if it is just one area of distress, maybe it is a psychiatry or financial consult. We think that this can be a useful benchmark to judge how physicians are doing in end-of-life care. Right now Medicare is judging us on whether or not a patient who dies and gets chemotherapy within the last 30 days, goes to hospice for a long enough time; things that are out of our control. What is in our control is whether we have that conversation at the right time. I think this is a good benchmark. The survey was published last year in the Journal of Palliative Medicine, and we are presenting additional information about it at this year’s ASCO meeting. Thank you.

Last modified: March 28, 2018