Oncologist, Dr Irene Hitchin, has seen first-hand the power of early referral palliative care, which is why she introduces palliative care to her serious cancer patients at the first consult – along with the curative treatment plan. The effects are powerful.
Clinical and radiation oncologist, Dr Irene Hitchin’s advanced cancer patients have a bit of an advantage. Dr Hitchin is a proponent of early referral palliative care so this means her patients are referred to a palliative care doctor as soon as they are diagnosed with with advanced stage or metastatic cancer (i.e. cancer that has spread from where it started to a distant part of the body). Her patients, who are still receiving active treatment from her, and may have months and even years to live, will meet their palliative care doctor and social worker to draw up an advance care plan, to talk through the prognosis, and assist with symptom control and any other issues that the patient – or their family – may have.
These patients may not need to see their palliative care doctor again for a while, but the advance care plan is in place, and relationships have been established. The patients know they have an extra layer of care and support when they need it, and Dr Hitchin knows she has an expert team to lean on when her patients are struggling with psychosocial issues, symptom control, or complex pain management. The palliative care team members can give these patients far more time than she can; and she can be allowed to focus on curative treatment.
Palliative care is not only for end-of-life
But not all oncologists refer early. There are still misconceptions that palliative care means a patient is dying so if a doctor is still administering cancer-directed therapy, that patient can’t be offered palliative care at the same time. Oncologists worry that by referring patients to palliative care, they will be depriving them of hope. Patients too, can be overly optimistic and will refuse palliative care. The result is that referrals to palliative care usually occur in the last weeks of life, leading to untreated symptoms, patient and family distress, and unnecessary aggressive treatments at the end of life.
Dr Hitchin saw early on in her medical career how powerful palliative care can be, for patients, for their family members, and even for herself as an oncologist. She witnessed first-hand what the evidence says about palliative care’s long list of benefits: relief from symptoms, better quality of life, brighter moods, greater satisfaction with care, fewer emergency room visits, and reduced burden on family caregivers.
“For over a year, I saw Mark monthly for his treatment. Mark would pop in to Dr V, and say, ‘I’m feeling fine. See you when I need you’.”
“Many years ago, before working as an oncologist, I was a medical officer at Stellenbosch Provincial Hospital, and I did sessions at the Stellenbosch Hospice, as the hospice doctor, part time. By the time I started my oncology private practice in Somerset West, I had had practical experience in palliative care, and I knew the benefit of it to patients. But I also saw how it could help me, as an oncologist… As you progress clinically, and your practice grows, you realise that that you don’t have all that time and resources to offer to patients in the palliative care setting,” says Dr Hitchin.
We work as a team
“I see it as a team effort, and from as early as possible. If your patient already has a relationship with the palliative care team – that is, they met when metastatic cancer was first diagnosed, suggesting the palliative care team gets more involved when the cancer progresses, doesn’t feel like I’m abandoning them. I always like to say to my patients: ‘We have to move the goalposts slightly but that doesn’t mean that I’m not involved anymore, I’m just less involved. And somebody else – your palliative care doctor – is more involved, but we are still working as a team’.
“And to deal with potential patient push-back and panic on suggestion of palliative care, I introduce it straight away – in the first consult with a metastatic cancer patient – along with the active treatment plan. That way, it gets normalised as part of the treatment.”
A medical collaboration in action
Dr Hitchin has an excellent example of how she worked with a palliative care doctor for one of her patients – Mark (not his real name), who had metastatic lung cancer. When he came to Dr Hitchin, he had some pain. His sister had also just been diagnosed with metastatic lung cancer in another town. She died within a couple of months of the diagnosis, so Mark’s emotional battle was big.
Dr Hitchin referred Mark to palliative care doctor, Dr V, at the same that she started him on monthly targeted chemotherapy. Dr V drew up an advance care plan with Mark, and they discussed symptom control.
“For over a year, I saw Mark monthly for his treatment,” says Dr Hitchin. “Mark would pop in to Dr V, and say, ‘I’m feeling fine. See you when I need you.’ And Dr V would check in from time to time too.”
As time passed, Mark developed a pleural effusion, or water on the lungs, and he became more symptomatic. At the same time, his wife was becoming very anxious. Dr V became more involved, supporting Mark, and his wife. Dr V was able to help them manage Mark’s symptoms at home, rather than him having to travel to Dr Hitchin, or the hospital.
“When Mark developed brain metastases, he was admitted to hospital. Dr V managed this, and managed his symptoms in hospital. We were able to get him home though, and have some radiotherapy, but then he deteriorated. His care at home was still managed by Dr V – someone who had built up a relationship with the whole family over two years, and they had access to social care, and nursing care. Mark and his wife felt well-looked after. It was a smooth transition of care over time from my side to palliative care, and the patient never once felt abandoned.”
Dr Irene Hitchin is a clinical and radiation oncologist at Cancercare, Panorama, Cape Town.
