Palliative Cancer Care in the Outpatient Setting: Which Model Works Best?

  • David HuiEmail author
Palliative and Supportive Care (MP Davis, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Palliative and Supportive Care

Opinion statement

Multiple randomized controlled trials have underscored the importance of timely referral to palliative care for patients with advanced cancer. Outpatient palliative care can facilitate timely referral and is increasingly available in many cancer centers. The key question is which model of outpatient palliative care is optimal. There are currently many variations for how palliative care is delivered in the outpatient setting, including (1) Interdisciplinary Specialist Palliative Care in Stand-Alone Clinics, (2) Physician-Only Specialist Palliative Care in Stand-Alone Clinics, (3) Nurse-Led Specialist Palliative Care in Stand-Alone Clinics, (4) Nurse-Led Specialist Palliative Care Telephone-Based Interventions, (5) Embedded Specialist Palliative Care with Variable Team Makeup, and (6) Advanced Practice Providers-Based Enhanced Primary Palliative Care. It is important to make a clear distinction among these delivery models of outpatient palliative care because they have different structures, processes, and outcomes, along with unique strengths and limitations. In this review article, we will provide a critical appraisal of the literature on studies investigating these models. At this time, interdisciplinary specialist palliative care in stand-alone clinics remains the gold standard for ambulatory palliative care because this approach has the greatest impact on multiple patient and caregiver outcomes. Although the other models may require fewer resources, they may not be able to provide the same level of comprehensive palliative care as an interdisciplinary team. Further research is needed to evaluate the optimal model of palliative care delivery in different settings.


Clinical trial Interdisciplinary health team Outcome and process assessment (health care) neoplasms Ambulatory care Palliative care 


Compliance With Ethical Standards

Conflict of Interest

David Hui has received research funding from Insys and Teva. He is also supported in part by grants from the National Cancer Institute (1R01CA214960-01A1, 1R01CA225701-01A1), the National Institute of Nursing Research (1R21NR016736–01), and the American Cancer Society (MRSG-14-1418-01-CCE).

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Portenoy RK, Thaler HT, Kornblith AB, Lepore JM, Friedlander-Klar H, Coyle N, et al. Symptom prevalence, characteristics and distress in a cancer population. Qual Life Res. 1994;3(3):183–9.CrossRefGoogle Scholar
  2. 2.
    Hui D. Definition of supportive care: does the semantic matter? Curr Opin Oncol. 2014;26(4):372–9.CrossRefGoogle Scholar
  3. 3.
    Hui D, Bruera E. Integrating palliative care into the trajectory of cancer care Nat Rev. Clin Oncol. 2016;13(3):159–71.Google Scholar
  4. 4.
    Kaasa S, Loge JH, Aapro M, Albreht T, Anderson R, Bruera E, et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol. 2018;19(11):e588–653.CrossRefGoogle Scholar
  5. 5.
    Hui D, Elsayem A, De la Cruz M, Berger A, Zhukovsky DS, Palla S, et al. Availability and integration of palliative care at US cancer centers. JAMA. 2010;303(11):1054–61.CrossRefGoogle Scholar
  6. 6.
    Davis MP, Strasser F, Cherny N. How well is palliative care integrated into cancer care? A MASCC, ESMO and EAPC Project. Support Care Cancer. 2015;23(9):2677–85.CrossRefGoogle Scholar
  7. 7.
    Davis MP, Strasser F, Cherny N, Levan N. MASCC/ESMO/EAPC survey of palliative programs. Support Care Cancer. 2015;23(7):1951–68.CrossRefGoogle Scholar
  8. 8.
    Hui D, Cherny N, Latino N, Strasser F. The ‘critical mass’ survey of palliative care programme at ESMO designated centres of integrated oncology and palliative care. Ann Oncol. 2017;28(9):2057–66.CrossRefGoogle Scholar
  9. 9.
    Gaertner J, Siemens W, Meerpohl JJ, Antes G, Meffert C, Xander C, et al. Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ. 2017;357:j2925.CrossRefGoogle Scholar
  10. 10.
    •• Haun MW, Estel S, Rucker G, Friederich HC, Villalobos M, Thomas M, et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017;6:Cd011129. Cochrane meta-analyses on early palliative care focusing on the advanced cancer setting.PubMedGoogle Scholar
  11. 11.
    Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, et al. Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. JAMA. 2016;316(20):2104–14.CrossRefGoogle Scholar
  12. 12.
    Davis MP, Temel JS, Balboni T, Glare P. A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses. Annals of palliative medicine. 2015;4(3):99–121.PubMedGoogle Scholar
  13. 13.
    Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer. 2014;120(11):1743–9.CrossRefGoogle Scholar
  14. 14.
    •• Hui D, Hannon BL, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. CA Cancer J Clin. 2018;68(5):356–76 Timely review providing more in-depth discussions on various contemporary models of palliative care and explaining the concept of interdisciplinary care in greater detail.CrossRefGoogle Scholar
  15. 15.
    Hui D, Bansal S, Strasser F, Morita T, Caraceni A, Davis M, et al. Indicators of Integration of Oncology and Palliative Care Programs: An International Consensus. Ann Oncol. 2015;26(9):1953–9.CrossRefGoogle Scholar
  16. 16.
    Hui D, Cherny NI, Wu J, Liu D, Latino NJ, Strasser F. Indicators of integration at ESMO Designated Centres of Integrated Oncology and Palliative Care. ESMO Open. 2018;3(5):e000372.CrossRefGoogle Scholar
  17. 17.
    Hui D, Masanori M, Watanabe S, Caraceni A, Strasser F, Saarto T, et al. Referral Criteria for Outpatient Specialty Palliative Cancer Care: An International Consensus. Lancet Oncol. 2016;17(12):e552–9.CrossRefGoogle Scholar
  18. 18.
    Hui D, Mori M, Meng YC, Watanabe SM, Caraceni A, Strasser F, et al. Automatic referral to standardize palliative care access: an international Delphi survey. Support Care Cancer. 2018;26(1):175–80.CrossRefGoogle Scholar
  19. 19.
    Hui D, Bruera E. Models of integration of oncology and palliative care. Ann Palliat Med. 2015;4(3):89–98.PubMedGoogle Scholar
  20. 20.
    Bruera E, Hui D. Integrating supportive and palliative care in the trajectory of cancer: Establishing goals and models of care. J Clin Oncol. 2010;28(25):4013–7.CrossRefGoogle Scholar
  21. 21.
    Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team: a controlled trial of outpatient Palliative Medicine consultation. Arch Intern Med. 2004;164(1):83–91.CrossRefGoogle Scholar
  22. 22.
    • Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42. Landmark randomized trial on outpatient palliative care.CrossRefGoogle Scholar
  23. 23.
    Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol. 2011;29(17):2319–26.CrossRefGoogle Scholar
  24. 24.
    • Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, et al. Early palliative care for patients with advanced cancer: a cluster-randomized controlled trial. Lancet. 2014;383(9930):1721–30. Landmark randomized trial on outpatient palliative care.CrossRefGoogle Scholar
  25. 25.
    Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA, et al. Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial. J Clin Oncol. 2016;35(8):834–41.CrossRefGoogle Scholar
  26. 26.
    Groenvold M, Petersen MA, Damkier A, Neergaard MA, Nielsen JB, Pedersen L, et al. Randomized clinical trial of early specialist palliative care plus standard care versus standard care alone in patients with advanced cancer: The Danish Palliative Care Trial. Palliat Med. 2017;31(9):814–24.CrossRefGoogle Scholar
  27. 27.
    do Carmo TM, Paiva BSR, de Oliveira CZ, Nascimento MSA, Paiva CE. The feasibility and benefit of a brief psychosocial intervention in addition to early palliative care in patients with advanced cancer to reduce depressive symptoms: a pilot randomized controlled clinical trial. BMC Cancer. 2017;17(1):564.CrossRefGoogle Scholar
  28. 28.
    Maltoni M, Scarpi E, Dall’ Agata M, Zagonel V, Berte R, Ferrari D, et al. Systematic versus on-demand early palliative care: results from a multicentre, randomized clinical trial. Eur J Cancer. 2016;65:61–8.CrossRefGoogle Scholar
  29. 29.
    Scarpi E, Dall’Agata M, Zagonel V, Gamucci T, Berte R, Sansoni E, Amaducci E, Broglia CM, Alquati S, Garetto F, Schiavon S, Quadrini S, Orlandi E, Casadei Gardini A, Ruscelli S, Ferrari D, Pino MS, Bortolussi R, Negri F, Stragliotto S, Narducci F, Valgiusti M, Farolfi A, Nanni O, Rossi R, Maltoni M (2018) Systematic vs. on-demand early palliative care in gastric cancer patients: a randomized clinical trial assessing patient and healthcare service outcomes. Support Care Cancer.
  30. 30.
    Maltoni M, Scarpi E, Dall’Agata M, Schiavon S, Biasini C, Codeca C, et al. Systematic versus on-demand early palliative care: A randomized clinical trial assessing quality of care and treatment aggressiveness near the end of life. Eur J Cancer. 2016;69:110–8.CrossRefGoogle Scholar
  31. 31.
    Tattersall MHN, Martin A, Devine R, Ryan R, Jansen J, Hastings L, et al. Early Contact with Palliative Care Services: A Randomized Trial in Patients with Newly Detected Incurable Metastatic Cancer. J Palliat Care Med. 2014;4(170):1–6.Google Scholar
  32. 32.
    Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302(7):741–9.CrossRefGoogle Scholar
  33. 33.
    Hui D, Shamieh O, Paiva CE, Khamash O, Perez-Cruz PE, Kwon JH, et al. Minimal Clinically Important Difference in the Physical, Emotional, and Total Symptom Distress Scores of the Edmonton Symptom Assessment System. J Pain Symptom Manag. 2016;51(2):262–9.CrossRefGoogle Scholar
  34. 34.
    Bakitas M, Tosteson T, Li Z, Lyons K, Hull J, Li Z, et al. Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol. 2015;33(13):1438–45.CrossRefGoogle Scholar
  35. 35.
    Hui D, Bruera E (2019) Models of Palliative Care Delivery for Cancer Patients. J Clin Oncol. (in press).Google Scholar
  36. 36.
    Meisenberg BR, Graze L, Brady-Copertino CJ. A supportive care clinic for cancer patients embedded within an oncology practice. J Commun Support Oncol. 2014;12(6):205–8.CrossRefGoogle Scholar
  37. 37.
    Prince-Paul M, Burant CJ, Saltzman JN, Teston LJ, Matthews CR. The effects of integrating an advanced practice palliative care nurse in a community oncology center: A pilot study. J Support Oncol. 2010;8(1):21–7.PubMedGoogle Scholar
  38. 38.
    Walling AM, D’Ambruoso SF, Malin JL, Hurvitz S, Zisser A, Coscarelli A, et al. Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic. J Oncol Pract. 2017;13(9):e792–9.CrossRefGoogle Scholar
  39. 39.
    Muir JC, Daly F, Davis MS, Weinberg R, Heintz JS, Paivanas TA, et al. Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manag. 2010;40(1):126–35.CrossRefGoogle Scholar
  40. 40.
    Rabow M, Small R, Jow A, Majure M, Chien A, Melisko M, et al. The value of embedding: integrated palliative care for patients with metastatic breast cancer. Breast Cancer Res Treat. 2018;167(3):703–8.CrossRefGoogle Scholar
  41. 41.
    Einstein DJ, DeSanto-Madeya S, Gregas M, Lynch J, McDermott DF, Buss MK. Improving End-of-Life Care: Palliative Care Embedded in an Oncology Clinic Specializing in Targeted and Immune-Based Therapies. J Oncol Pract. 2017;13(9):e729–37.CrossRefGoogle Scholar
  42. 42.
    Dyar S, Lesperance M, Shannon R, Sloan J, Colon-Otero G. A nurse practitioner directed intervention improves the quality of life of patients with metastatic cancer: Results of a randomized pilot study. J Palliat Med. 2012;15(8):890–5.CrossRefGoogle Scholar
  43. 43.
    McCorkle R, Jeon S, Ercolano E, Lazenby M, Reid A, Davies M, et al. An Advanced Practice Nurse Coordinated Multidisciplinary Intervention for Patients with Late-Stage Cancer: A Cluster Randomized Trial. J Palliat Med. 2015;18(11):962–9.CrossRefGoogle Scholar
  44. 44.
    Fadul N, Elsayem A, Palmer JL, Del Fabbro E, Swint K, Li Z, et al. Supportive versus palliative care: what’s in a name?: a survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2009;115(9):2013–21.CrossRefGoogle Scholar
  45. 45.
    Hui D, Cerana MA, Park M, Hess K, Bruera E. Impact of Oncologists’ Attitudes Toward End-of-Life Care on Patients’ Access to Palliative Care. Oncologist. 2016;21(9):1149–55.CrossRefGoogle Scholar
  46. 46.
    Wong A, Reddy A, Williams JL, Wu J, Liu D, Bruera E, et al. Attitudes, Beliefs, and Awareness of Graduate Medical Education Trainees Regarding Palliative Care at a Comprehensive Cancer Center. J Oncol Pract. 2016;12(2):149–50.CrossRefGoogle Scholar
  47. 47.
    Hui D, Kilgore K, Park M, Liu D, Kim YJ, Park JC, et al. Pattern and Predictors of Outpatient Palliative Care Referral Among Thoracic Medical Oncologists. Oncologist. 2018;23(10):1230–5.CrossRefGoogle Scholar
  48. 48.
    Hui D, Finlay E, Buss MK, Prommer E, Bruera E. Palliative Oncologists: Specialists in the Science and Art of Patient Care. J Clin Oncol. 2015;33(20):2314–7.CrossRefGoogle Scholar
  49. 49.
    Hui D, Titus A, Curtis T, Ho-Nguyen VT, Frederickson D, Wray C, et al. Implementation of the Edmonton Symptom Assessment System for Symptom Distress Screening at a Community Cancer Center: A Pilot Program. Oncologist. 2017;22(8):995–1001.CrossRefGoogle Scholar
  50. 50.
    Fischer SM, Kline DM, Min SJ, Okuyama-Sasaki S, Fink RM. Effect of Apoyo con Carino (Support With Caring) Trial of a Patient Navigator Intervention to Improve Palliative Care Outcomes for Latino Adults With Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol. 2018;4(12):1736–41.CrossRefGoogle Scholar
  51. 51.
    Barnard ND, Willett WC, Ding EL. The Misuse of Meta-analysis in Nutrition Research. JAMA. 2017;318(15):1435–6.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Palliative Care, Rehabilitation and Integrative MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of General OncologyMD Anderson Cancer CenterHoustonUSA

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