Issue No. 2013
Meet Tom Smith
Date: January 3, 2013
The Benefits of Palliative Care
Thomas J. Smith, M.D., is one of the world's leading experts in palliative care and an accomplished cancer clinician and researcher. He has recently joined the faculty of the Kimmel Cancer Center as the Harry J. Duffey Family Professor of Palliative Medicine and Director of Palliative Medicine at Johns Hopkins. Smith shared his thoughts on the evolution of palliative care and his goals for the Kimmel Cancer Center.
What is palliative care?
I usually tell people that it is hard to define, but you know it when you see it. In literal terms, it means the management of symptoms-controlling pain, shortness of breath, depression, anxiety and those things that affect patients' quality of life. The greatest misperception is that palliative care is only end-of-life care. In fact, it is survivorship care. We now know that palliative care is beneficial for all patients with advanced cancer from the time of diagnosis, not just at the end of life.
Palliative care was introduced as a medical specialty in 1990, but just a handful of hospitals offered it. Today, 90 percent have some type of palliative care program or service.
What caused the big shift?
There were a couple of things that happened. First and foremost, we proved that palliative care had a favorable impact on survival. Two separate studies found that patients with advanced cancer who received palliative care lived longer than patients who did not. A study of lung cancer patients showed that those who had palliative care from the onset, used less chemotherapy at the end of their lives, spent less time in the hospital, and lived three months longer. The same results were seen in other studies. These findings led the American Society of Clinical Oncology to recommend that every seriously ill cancer patient get palliative care.
Secondly, it reduced costs. Effective symptom management keeps patients out of the hospital, and as a result, there is a significant cost savings.
Managing burgeoning health care costs, whether we like it or not, is part of our reality. Insurance premiums for a family of four have risen from $7,000 to over $15,000 in the last ten years. Patients are faced with it when they consider expensive treatments with large copays, and providers of care need to think about it too. We simply cannot sustain these rising costs. When we looked at our own patients, we found that one-third had chemotherapy within two weeks of their deaths. There is more and more evidence that this is not helpful, and in fact, it could be harmful and actually shorten peoples' lives. More money does not always translate into better care, and by the same token, spending less money does not equate to lesser care. We need to recognize when continuing chemotherapy or radiation therapy is no longer the best thing for the patient.
What is the Kimmel Cancer Center doing to develop its palliative care program?
The first thing we did was to evaluate our own performance to see where there was room for improvement. We have an excellent team of palliative care providers that includes physicians, social workers, and nurses, but we also recognize there are things we can do better. For example, I think we can do a better job of talking to patients and asking them about their goals. Focusing on quality of life is just as important, and sometimes more important, than focusing on the number of cancer cells in the body.
An American Cancer Society study found that just one in four cancer patients felt they had adequate treatment of their symptoms, such as pain and shortness of breath. One in three felt they were getting adequate emotional support, and half said they would have benefitted from more education on how to manage pain and control symptoms when they were discharged from the hospital. As providers of care, we may think we explain these things, but that is not always the patient perception. We have to ask patients: Are you bothered by pain, anxiety, or shortness of breath? What can I help you with? What did you understand from what we talked about? We have to make sure that we're not only giving the message but that our message was received and understood by patients and families.
Too many patients are dying in the hospital. It's not good for them or their families. They don't want to be there. I would like to see hospice care integrated sooner for patients because patients who have good palliative care and hospice care tend to live longer. It should be part of the normal process of care for any patient who has an advanced cancer that we cannot cure. Then, when a third-line treatment doesn't work, patients can make a smooth transition to this team.
What do you have planned for the pain and palliative care program?
I would like to see Johns Hopkins where it rightfully should be, a national leader in palliative care. The Duffey family shares our vision, and we are fortunate because they have provided us ongoing funding to make this happen. We plan to add doctors and advanced practice nurses to our team. Currently, we have outpatient and inpatient palliative care consultations are outpatient. By 2013, we hope also to have an inpatient unit.
We have already established a palliative care research fellowship and have received two research grants. We would like to add a clinical fellowship. We are establishing and expanding interdisciplinary relationships with the School of Public Health and the School of Nursing to ensure we are truly providing the best and most advanced care possible in keeping with the Johns Hopkins tradition.