"Despite stepped-up efforts to educate nurses on EOL and palliative care, oncology nurses are unfortunately receiving less education about palliative care than they did a decade ago." --Kenneth R. White, PhD, MSN, RN, and Patrick J. Coyne, MSN, APRN, ACHPN, ACNS-BC, FAAN, FPCN
 
The above is a statement from a landmark survey study article titled ""Nurses’ Perceptions of Educational Gaps in Delivering End-of-Life Care."[Onc Nurs Forum. 2011;38(6):711-17.] This is a 10-year follow-up study that involved "714 members of the Oncology Nursing Society from Georgia, Virginia, Washington, and Wisconsin." [One of the purposes of the survey was to determine if oncology (cancer) nurse specialists are receiving more continuing education about palliative care topics.] The findings: "Almost all of the respondents indicated that EOL [end-of-life] care was a part of their practice and that continuing education was important, but more than half of the respondents had fewer than two hours of continuing education regarding EOL care in the past two years."And..."Given that a decade has passed since the previous study (White et al., 2001), which included a question about the amount of EOL continuing education in the previous two years (1997–1999), it is surprising that the percentage of respondents who had received any EOL continuing education education in this study (2007–2009) had decreased from 74% in 1999 to 63% in 2009."  For this group sample, "The mean time since becoming licensed as a nurse was 21.3 years, and the mean age was 48.5 years (range = 24–79 years)." 
 
 
 
"Principal obstacles to the provision of palliative cancer care are the lack of political will, lack of drug availability, need for trained providers, and need for education of the public and leaders in public health, health systems, the healthcare professions, and government. Globally, the conquering of these hurdles and relief of human suffering demands concerted, coordinated, and vigorous action." --David C. Currow, BMed, MPH, FRACP,  Jane L. Wheeler, and Amy P. Abernethy
 
The above statement is from the perspective article "International Perspective: Outcomes of Palliative Oncology." [Semin Oncol. 2011;38:343-350.] In there opening to the article they state that "This year, globally, more than 8 million people will die as a direct result of cancer, many of whom will have had their lives substantially shortened, eclipsing the annual mortality of AIDS, malaria, and tuberculosis combined. By 2030, the annual death toll from cancer is expected to rise to 17 million, and 75 million people are projected to be living with a cancer diagnosis."
 
"There is no argument that palliative care should be integrated into cancer care from diagnosis to death. " --Kathleen M. Foley, M.D

The above statement by Dr. Foley who was the editor of a comprehensive 325 page report released in 2001 by the National Cancer Policy Board, National Research Council called "Improving Palliative Care for Cancer: Summary and Recommendations." Also within this landmark investigative report was the statement that "The current inadequacy of palliative and end-of-life care springs not from a single cause or sector of society, but from institutional and economic barriers, lack of information about what can be achieved, lack of training and education of health care professionals, and minuscule public sector investments in research to
improve the situation. This is not to suggest that there is no ongoing research on relevant questions or training programs-there are-but the efforts are not coordinated, and there is no locus for these activities in any federal agency."

"Three-quarters of cancer patients worldwide are incurable when diagnosed." --Jan Stjernsward, MD, PhD, FRCP (Edin), Kathleen M. Foley, MD, and Frank D. Ferris, MD

The above statement is from the article "Integrating palliative care into national policies". The authors' indicate the global need for palliative care. In their abstract, they provided the following summary of the article and emphasized that "Because the size of the problem and the suffering associated with cancer is enormous, development of a national cancer control policy is an effective point of entry to begin integrating palliative care into a country's health care system. To be comprehensive, every cancer center must include palliative care. Ideally , palliative care is incorporated as a priority within all aspects of each country's national health plan, so that all patients living with or dying from any chronic disease may have their suffering relieved, including children and the elderly." Some details of how to get national policies adopted in a country were provided , including "National policies are typically developed through a process that starts by advocacy to increase global and local awareness and change attitudes about the importance of the subject. Once interest is expressed, meetings are held with key leaders to sensitize them to the size of the problem, opportunities for improved quality of life, and more cost-effective health care services to provide strategies to address the challenges of integrating palliative care policies. Once there is uptake, policymakers and regulators can use existing policies as samples or create their own national policies." They also discussed the need for an international consensus from advocacy groups who can help push a movement into a policy. That is "There are many consensus-based advocacy documents that convey the importance ofpalliative care in cancer care, AIDS care, and elder care. Each advocacy document aims to increase the awareness of policymakers and the public about the size of the problem and solutions, the importance ofpalliative care as a human right and responsibility, and the integration ofpalliative care with disease management strategies to provide more comprehensive care." To summarize their article, they stated that  "Good policies lay the groundworkfor an effective health care system and society . To ensure the best possible implementation ofpalliative care in a country, it must be incorporated in the National Health Plan and all related policies and regulations so that affordable medications are widely available, and palliative care education and services are integrated into the health care system and society at all levels."

"Sadly, the cure ratefor cancer overall remains less than 60%,and cancer continues to accountfor more than 25% of all adult deaths. " --Nathan Cherney, MBBS, FRACP, FRCP

The above statement is from the article "The oncologist's role in delivering palliative care." [The Cancer Journal. 2010;16(5):411-22. PubMed] The remainder of the above statement was "For many patients, cancer is a chronic illness that ultimately results in death, and for this population, the issues surrounding the quality oflife are critical, irrespective of the clinical course of their illness or the duration ofsurvival. The care ofpatients with cancer must, therefore, include a quality-of-life dimension incorporating a continuum in patient care in which both primary therapies and palliative interventions are integrated according to the clinical circumstances of the patient. "And then latter in the article, a statement was included in a definition of palliative care and indicated that "Palliative care is care that aims to optimize the comfort, junction, and social support of the patient and his/herfamily when cure is not possible."

Even though cure is not possible, the point when patient's with life-limiting conditions become incurable may be many years before they reach their end of life. One thing that was not addressed in the above article is the importance of oncologist's discussing advance care plann ing with their patients, since most cancer patients who are diagnosed with cancer will die from it. There was a statement made that "Very often, the timing of referrals to specialized palliative care services, including palliative care units, inpatient hospices, and home-based palliative care programs, is delayed until patients have severe symptom burden or are close to
death." And for many patients, this is the point when advance directives (end-of-life treatment preferences) are discussed, which is why many hopeless patients end up in the intensive care unit (leU) and on multiple life-sustaining therapies for a prolonged period before dying.

"Formal assessment of cancer palliative and supportive care guidelines has, to date, been scarce, and additional assessment is clearly needed to justify uptake."  -- S. Yousuf Zafar, MD, MHS, David C. Currow, BMed, MPH, FRACP, Christopher K. Daugherty, MD, and Amy P. Abernethy, MD

The above statement is from the article "Standards for Palliative Care Delivery in Oncology Settings" [Cancer J . 2010 Sep-Oct;16(S)=436-43. PubMed] In the beginning ofthe next paragraph, there is the statement that  "The scarcity of formal assessment might be due to insufficient uptake of or adherence to guideline-based care, even in the usual setting. In general, the dissemination of clinical guidelines has not rapidly impacted physician behavior. Barriers to guideline adherence have been described; they include lack ofawareness orfamiliarity, lack of agreement with guidelines, lack of outcome expectancy, lack of self-efficacy, and inertia ofprevious practice. Nonadherence to guidelines is evident specifically in the palliative care realm, as well."
 
Links:

NCCN Clinical Practice Guidelines in Oncology

• A total of 1,638,910 new cancer cases and 577,190 deaths from cancer are projected to occur in the United States in 2012. --Rebecca Siegel, MPH; Deepa Naishadham, MA, MS2; Ahmedin Jemal, DVM, PhD [Cancer Statistics, 2012. CA Cancer J Clin 2012;62:10–29.]