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Who’s talking to who during transitions

Commentary by Dr. Martin Chasen

Commentary by Dr. Martin Chasen

The article by Ullgren, Kirkpatrick et al entitled “Working in silos? – Head & Neck cancer patients during and after treatment with or without early palliative care referral” (1) describes how care transition from acute oncological treatment to home palliative care impacted on QoL and informational needs.

Data was collected from 203 patients out of 289 patients (70%) which is a better than expected number of respondents to electronic surveys. The results indicate that the lowest reported functional scale was global health and fatigue was the highest. Patients with a written care plan were more satisfied with the information regarding selfcare compared to patients not having a written care plan.

The disturbing finding was the following statistically significant findings:

  1. Patients referred to palliative care were less satisfied with information regarding their disease (p<0.000) and spread of the disease (p<0.001).

  2. They were more likely to visit an emergency department (p<0.000).

This finding is counter-intuitive to our modern day thinking that early palliative care consultation leads to a longer survival and less chemotherapy being administered as was shown by Temel et al (2). Now, in the article by Ullgren, taking into consideration that there were more patients who had multimodal therapy and less single mode of therapy in the palliative care group could suggest these patients had more advanced disease. Also considering that the services provided were home-based only and that these patients referred to palliative care would have lost the services of the contact nurse may also have played a role in the less patient satisfaction which was recorded. However, this study and others bring to the front burner the growing evidence that communication between teams of professionals needs to be addressed with the patient and family needs at the center of the discussion, in order to improve the transition phases that patients undergo during their disease trajectory.

In a study of 230 patients with breast, colon and lung cancer, about 1 year after their diagnosis, most survivors still regarded their oncologist as the main health care professional for follow-up (3). Care and coordination between family physicians (FP) and specialists is necessary to ensure that patients’ health needs are met during and after treatment. Patients do not see FP as knowledgeable enough about follow-up and management of cancer-related problems and FP very often feel completely ignored and “left out of the loop”. Communication gaps that occur during transitions can create confusion, insecurity and even abandonment (4).

One solution is to plan for discharge very much like at the time of a hospital admission one plans for discharge. So too, transition planning should begin during treatment planning and involved palliative care physicians and nurses should be kept up to date in writing as to what progress is being made. Furthermore, continued education of family and friends and community supports will in future need to be considered as we move into an era when it is predicted that the health care workforce dealing with and caring for patients with cancer will not keep pace and by 2025 supply will not meet demand (5).

More effective communication between health care providers will engender greater understanding and confidence between all involved professionals which will lead to better care and improved patient satisfaction.

1. Ullgren H, Kirkpatrick L, Kilpeläinen S, Sharp L. Working in silos? – Head & Neck cancer patients during and after treatment with or without early palliative care referral. Eur J Oncol Nurs 2017; 26: 56–62 

2. Temel JS, Greer JA, Muzikansky A et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363: 733–42

3. Chubak J, Aiello Bowles EJ, Tuzzio L et al. Perspectives of cancer survivors on the role of different healthcare providers in an integrated delivery system. J Cancer Surviv 2014; 8: 229–38

4. Thorne S, Hislop TG, Kim-Sing C et al. Changing communication needs and preferences across the cancer care trajectory: insights from the patient perspective. Support Care Cancer 2014; 22: 1009–15

5. HIS INC. The complexities of physician supply and demand: projections from 2013–2025. Prepared for Association of American Medical Colleges


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