Meeting Palliative Care Recommendations in Advanced Cancer Patients

November 2018 Vol 9, NO 11
Ellen Terwilliger, RN, MSN, ONN-CG
Sarah Cannon with HCA Midwest

Background: Palliative care is a collaborative approach that improves quality of life for patients and families but is often provided too late.

Objectives: The aim of this quality improvement project was to provide an evidenced-based presentation describing the importance of early introduction of palliative care, the success of other clinic settings in utilizing EHR alerts to improve patient screening results, and assess its effectiveness in increasing provider interest in generating an EHR alert for palliative care consultation in the oncology clinic. The EHR alert serves as a small step toward a larger outcome goal of earlier consultation of palliative care services for advanced-stage cancer patients.

Methods: Evidence was gathered by comprehensive literature search of early palliative care, advanced cancer patients, EHR alert, and clinical decision support using National Guideline Clearinghouse, Cochrane Library, EBSCO Host, CINAHL Complete, and Google Scholar. Search criteria included adult populations from 2010 to present and excluded results that were not English language and full-text PDF. Over 200 articles were screened for eligibility in the literature review. This was synthesized to 10 main articles, 2 guidelines of practice, and the American College of Surgeons Commission on Cancer standards. Additional oncology clinic–specific data were analyzed that reviewed new patient consults between 11/27/17 and 1/16/18; 114 patient cases were reviewed that yielded 20 stage III and 22 stage IV patients. The advanced cancer patient’s charts were reviewed for ECOG score and whether palliative care had been consulted. The literary evidence and oncology clinic–specific data were synthesized for presentation to the oncology clinic’s providers. Three medical oncologists and 1 nurse practitioner were present to hear the information and surveyed at the completion of the presentation.

Results: Literary evidence showed early intervention of palliative care provided the most improvement in quality of life. It also showed EHR alerts were effective in triggering providers and screening patients. The clinic-specific data showed no palliative care consultations, which highlighted the very common gap that palliative care consultations occur too late in the advanced cancer patient’s disease trajectory. Although the project was limited by the small sample size and duration, the providers unanimously agreed about the importance of palliative care for advanced cancer patients. However, providers did not feel implementation of an EHR alert would benefit their oncology clinic.

Conclusions: It was concluded that lacking a dedicated palliative care team for their health system needed correction first, and further follow-up is needed. Implications for EHR alert use could still be applied in outpatient clinic settings if the main barriers include needing to trigger providers and screen patients. Additional extrapolation could also be made that navigation could help increase the number of patients reaching palliative care. A navigation-specific process was not studied at this time; however, it does lead to an opportunity for additional research. Navigation could implement a process to improve the consult process, or does a navigator increase the likelihood a patient will receive early palliative care consultation as recommended in national guidelines of practice and randomized controlled trials? Navigators serve to advocate for their patients and coordinate their needs, and as such there is a unique opportunity to assist in promoting that their patients receive a consult with palliative care early in their disease trajectory.


Aldridge MD, Hasselaar J, Gerralda E, et al. Education, implementation, and policy barriers to greater integration of palliative care: a literature review. Palliat Med. 2016;30:224-239.
American College of Surgeons. Oncology medical home standards. 2017.
Dionne-Odom JN, Azuero A, Lyons KD, et al. Benefits of early versus delayed palliative care to informal family caregivers of patients with advanced cancer: outcomes from the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33:1446-1452.
Federman AD, Kil N, Kannry J, et al. An electronic health record-based intervention to promote hepatitis C virus testing among adults born between 1945 and 1965. Med Care. 2017;55:590-597.
Gomes B, Calanzani N, Curiale V, et al. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013;6:CD007760.
Griffith J, Lyman JA, Blackhall LJ. Providing care in the ambulatory care setting. Clin J Oncol Nurs. 2009;14(2):171-175.
Guiriguet C, Muñoz-Ortiz L, Burón A, et al. Alerts in electronic medical records promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care. Br J Gen Pract. 2016;66:e483-e490.
Kamal AH, Gradison M, Maguire JM, et al. Quality measures for palliative care in patients with cancer: a systematic review. J Oncol Pract. 2014;10:281-287.
Marcelin JR, Tan EM, Marcelin A, et al. Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study. BMC Med Inform Decis Mak. 2016;16:1-11.
Medical Services Commission of British Columbia. Guidelines and Protocol Advisory Committee. Palliative Care for the Patient with Incurable Cancer or Advanced Disease, Part 1: Approach to Care. ative-care-approach. 2010.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Palliative Care. 2017.
National Institute of Health. National Cancer Institute. Cancer Statistics. 2017.
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;363:733-742.

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