Incorporating palliative care into cancer treatment protocols can improve patient quality of life, lower costs and lengthen survival. As part of Medicare’s shift from volume to value-based metrics, it began covering palliative advanced care planning as a separate and billable service in 2016.

Still, integrating palliative care is not easy. Significant barriers include limited palliative resources, rising health care costs and physician buy-in. “Balancing treatment recommendations from multiple consultants is a tough task,” said Lisa Kachnic, M.D., professor and Cornelius Vanderbilt Chair of Radiation Oncology at Vanderbilt University Medical Center. “For us as radiation oncologists, the challenge is to develop highly individualized, timely palliative treatment strategies without exhausting outpatient resources and personnel.”

Kachnic and colleagues recently helped launch Vanderbilt’s Inpatient Palliative Radiation Oncology Service (inPROV). The service consists of a dedicated attending-resident-nurse practitioner team that provides approximately 350 to 400 bedside consultations annually. The goal of the new service is to work alongside the palliative and oncology care teams to provide an extra layer of support for patients. A special article in Practical Radiation Oncology describes the new service at Vanderbilt and its influence to date.

Case Studies Demonstrate Benefits of Consults

“These cases illustrate the importance of explicitly articulating patients’ goals for care and integrating that information with prognosis.”

The article discusses four cases in which inPROV helped improve outcomes. Two cases highlight unconventional, short radiation approaches for individuals with poor prognoses. “Although it stands that shorter radiation courses may be associated with greater long-term side effects, most patients with poor prognosis will not live long enough to experience these side effects,” wrote the authors. “Late toxicities should not overshadow best care.”

The other two case studies highlight the importance of working with patients to set care goals. In one case, the patient felt radiation would detract from her goals and lessen her quality of life. In the final case, only a single, small fraction of radiation was used to help a patient regain functional independence, and the team did not elect for other oncologic therapies.

“These cases illustrate the importance of explicitly articulating patients’ goals for care and integrating that information with prognosis,” said Kachnic. “They also show how important it is that palliative radiation oncologists recognize the trajectories of the diseases they treat.”

Quantifying Benefits

During the first 10 months of inPROV’s inception, inpatient palliative radiation consults increased by 35 percent. Goals of care and prognosis were documented in 65 percent of radiation oncology consult notes, and short course radiation therapy (≤5 fractions) increased from 30 percent to 70 percent. The median length of stay declined from 21 days to 9.

The benefits are due in part to daily bedside rounds that facilitate adjustments in radiation plans as needed, and increased efficiency in care team coordination. When patients decline treatment, they now have a multidisciplinary team to discuss the case and help transition them to Vanderbilt’s outpatient palliative care clinic or hospice. Family meetings with the inPROV team also help uncover specific details about patient goals. The team’s preliminary results show inPROV has helped establish new delivery methods for innovative, collaborative care.

Zak Kohutek, M.D., joined Vanderbilt’s Department of Radiation Oncology in October 2018, to lead the inPROV service alongside Theresa Cressman, M.S.N. Kohutek immediately recognized the service’s benefits. “It’s clear inPROV improves patient care on all fronts. It allows us to better integrate palliative radiation into the overall care plan for patients, improves communication with patients and their families and efficiently brings personalized radiation oncology interventions and expertise to some of the sickest and most vulnerable patients in the health care system.”

About the Expert

Lisa Kachnic, M.D.

Lisa Kachnic, M.D., FASTRO, is professor and Cornelius Vanderbilt Chair of the Department of Radiation Oncology at Vanderbilt University Medical Center. Her research and clinical interests include rectal and anal malignancies, image-guided radiation delivery, and developing novel approaches for outcomes/symptoms management.

Zak Kohutek, M.D.

Zak Kohutek, M.D., is assistant professor of radiation oncology at Vanderbilt University Medical Center. He is also assistant program director of the Department of Radiation Oncology medical residency program.

Theresa Cressman, M.S.N.

Theresa Cressman, M.S.N., ACNP-BC is nurse practitioner in the Department of Radiation Oncology at Vanderbilt University Medical Center. She is also a Vanderbilt University graduate, where she earned her master’s degree in nursing.