Unquestionably, timely referral to palliative care is helpful for patients with poor prognosis cancers yet it’s not the same as a referral to any other specialty as it’s loaded with meaning, stigma and uncertainty.

Can it be done better without feeling “weird”? Definitely, according to palliative care physician Dr Joanne Doran, from the Gold Coast University Hospital.

She told the Clinical Oncology Society of Australia (COSA) 2024 ASM that the benefits of palliative care include improved survival, improved symptom control, less anxiety and depression, reduced use of futile chemotherapy, improved patient and family satisfaction and the improved use of healthcare resources.

“If this was a drug, you wouldn’t be here listening to me, you’d be on your phones buying shares. This is a good thing that we can do for our patients and their families. So if it’s so good, why is it weird, and why do we have barriers?,” she said.

One problem is that palliative care, or even the more innocuous-sounding supportive care, carries the message and associated stigma that the patient has an incurable disease that eventually is going to lead to their death.

Dr Doran said she suspects palliative care teams haven’t done a very good job of communicating that it’s not just about death and dying.

On the flipside, the idea that oncology and other colleagues appear to have a lack of confidence in the quality of the palliative care services or do not take the time to develop relationships was somewhat hurtful.

She said oncologists can’t refer to palliative care unless they have talked with their patient about prognosis and there were many reasons why they struggled to do this.

“Dread is a word there, not wishing to destroy hope, struggling to balance sensitivity with honesty, fear of damaging relationships [with patients], determining whether and how to share information, determining how to assess what the patient wants to know, and being sensitive to cultural and family issues.”

“This is not a tale of wilful paternalism. To me this is a tale of moral distress and I know that the burnout rate in oncologists is much higher than in palliative care clinicians. It’s difficult.”

She said clinicians’ own discomfort with death, dying, bereavement and loss, feelings that they’ve given up on, abandoned or failed a patient, and their own sense of helplessness and hopelessness all needed to be considered.

Dr Doran said evidence showed that the main reason why doctors provide futile treatment is because they are trained to treat.

“We’re not trained to not treat or withhold or withdraw – that feels very uncomfortable to us. We don’t like to give up hope.”

Other concerns were, increasingly, legal risk, poor communication skills or training, and emotional attachment to patients.

She said the doctors who were least likely to provide futile care were the more experienced doctors, those who’ve previously witnessed a bad death from futile treatments and those who had experienced a family member dying.

Dr Doran said it should be reassuring to clinicians that, in fact, informed patients do not automatically lose hope or become depressed or distressed.

“There’s this issue of duality of hope…so we have extrinsic hope, and that’s what we all think about with a cancer diagnosis – that I’m going to get better, I’m going to be cured. And then there’s an intrinsic hope …[which] becomes of more value and that’s about internal sources of nourishment and repair, about healing, meaning making, and the value of personhood.”

“If you talk to anyone who has cared for someone who’s dying, they will tell you that hope exists in two camps – I’m getting better and I understand what is happening – and they coexist.”

Dr Doran said clinicians can learn to be the empathic professional their patients need and the key was communications skills training.

“The empathic professional not only helps the patients with the transition, but builds rapport and improves the patient’s ability to cope with the disease.”

“Bad news is bad news. There’s no amount of communication skills training that can make bad news good news, and nor should we. Good communication is never harmful… good communication with rapport building might be the only thing you have left that might influence their quality of life.”