Delivering Palliative Care to Cancer Patients Through TELEHEALTH

For cancer patients who are not hospitalized, providing palliative care brings many challenges.

Palliative care consists of treatments aimed at improving quality of life for people with serious and/or progressive illness, from diagnosis throughout the course of the disease. Palliation, literally meaning "temporary remedy, covering over," is often seen as supportive treatment given in the terminal (final) stage, but palliative treatments are provided throughout the illness. To put it more clearly: In a serious illness such as cancer, both the disease itself and its treatment can have many effects that disrupt a patient’s comfort. These may include pain, nausea and vomiting, diarrhea, edema, urinary and kidney problems, widespread fatigue, psychological problems, and more. The approach needed to help people carry out daily activities, perhaps continue earning a living despite serious illness, or at least experience the difficulties of illness as mildly as possible is called "palliative care / supportive treatment."

Can palliative care be delivered through telehealth?

According to REACH PC research, "telehealth / telemedicine" may offer a solution to these challenges. Of course, this approach has its own problems.

Telehealth is a service that uses networks such as the internet to deliver healthcare over a distance, without requiring the doctor and patient to be in the same place at the same time.

From Massachusetts Hospital in Boston, Dr. Jennifer Temel discussed telehealth in palliative care in light of REACH PC findings during the educational session of the ASCO Quality Care Symposium, held virtually in 2020.

Dr. Temel noted that in-hospital palliative care may cost cancer patients more time, money, and energy.

Having an adequate palliative care clinic is a substantial undertaking for hospitals, requiring financial investment and the employment of healthcare professionals.

Such problems make telehealth an attractive option for palliative care.

A shortage of palliative care specialists

Annual Report on Community Health reported in 2014 that the United States had only 1 palliative care specialist for every 20,000 adults.

The 2019 State report stated that only 72% of US hospitals had a palliative care center with 50 or more beds.

For people with serious illnesses who are disadvantaged by where they live and their socioeconomic circumstances, palliative care is only a dream.

Shortcomings in the current system make these disadvantages more pronounced. Many palliative care specialists can see patients only when they come to hospital for other clinic visits. This prevents specialists from providing a better service.

Special considerations for telehealth in palliative care

There are drawbacks to telehealth in palliative care. One is the difficulty of conveying warmth, contact, and concern through video.

Palliative care specialists must inform patients about many important and sensitive issues, such as prognosis and advance directives. How patients and their families understand these conversations over video remains uncertain.

There are also obstacles to prescribing opioids through video consultations.

Despite these concerns, the ENABLE study demonstrated that weekly educational palliative care delivered by telephone alongside oncology treatment improved quality of life compared with oncology treatment alone. The research was published in 2009 in JAMA.

The REACH PC telehealth feasibility study

Temel described the ongoing REACH PC study, which compares palliative care delivered by video with care delivered through direct hospital visits in patients with advanced large-cell lung cancer.

The main aim of REACH PC is to determine whether telehealth produces equivalent outcomes for oncology patients receiving palliative care compared with other patients.

At present, REACH PC has enrolled 581 patients at 20 sites across a wide and diverse geographical area. These represent only half of the patients approached. 1250 patients were contacted about the research.

Among patients who declined participation, 7.6% cited "distrust of technology." Most nonparticipants reported a lack of interest in the research (35.1%) and/or in palliative care (22.9%).

Older adults make up the majority of participants. 60% are over age 60, and 1 in every 3 participants is over age 70.

Among participants, discontinuation was higher in the telehealth group than in those receiving care in person (13.6% versus 9.1%)

When asked about video care, 64.3% of palliative care specialists reported no difficulties. This was almost the same as the 65.5% rate for in-person care.

Most problems specialists experienced during video care were technical (19.1%). Only 1.4% reported feeling uncomfortable providing care by video, and 1.5% reported difficulty establishing rapport with the patient.

Video etiquette

Strategies such as responding while listening and summarizing what the patient has said to show full understanding are key behaviors for success in palliative care

Dr. Temel recommends a technique she calls "video etiquette" to help specialists compensate for the patient contact they miss in video care. It involves looking at the camera while the patient speaks, nodding to show that you are listening, and pausing before speaking to make sure the patient has finished.

Is telehealth the future of palliative care?

I should say that I am among the oncologists who have voiced concerns about moving complex consultations such as palliative care from face-to-face encounters to telehealth. Nevertheless, the early results of REACH PC demonstrate that telehealth is a very valuable tool.

To minimize the difference between face-to-face care and telehealth, we must identify more detailed practical strategies for building trusting relationships and rapport with patients.

We must also be more alert to inequalities created by abrupt changes in care arising from technology use. Based on telehealth experience during the COVID-19 pandemic, researchers at Houston Methodojik Cancer Center reported that patients declined telehealth services for reasons such as older age, low income, and lack of insurance. This research was published in PCO Oncology Practice.

For these reasons, a hybrid system will probably always be needed in palliative care.

Finally, we should heed the advice in Alvin Toffler’s Future Shock. In the book, Mr. Toffler says, "The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn."

The traditional model of palliative care will always need to be relearned.

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