Oncology Teams: Achieving Goal-Concordant Care and Improving Pain and Symptom Management
Improving quality of life for cancer patients and their families reduces suffering, reduces preventable readmissions, and improves quality outcomes.
To achieve these goals, oncologists need the skills to have effective conversations with patients and families about their treatment goals and to safely manage pain and other symptoms. When patient needs are especially acute—complex pain and symptoms or conflicts among patient, family, and physician—oncologists often consult the specialty palliative care team for an added layer of support.
This toolkit contains training and clinical tools for oncology clinicians from all disciplines.
Download a course catalog with information about continuing education credits and ABIM MOC points for all CAPC courses here.
What’s in the Toolkit
Communicate about what matters to patients and families in order to create a care plan aligned with what is most important to them.
How to initiate and conduct conversations about advance care planning.
Strategies for eliciting patient goals and preferences to inform treatment decisions.
Communication techniques for an effective family meeting.
Communicating serious clinical news to patients and families.
How to discuss patient prognosis in a manner that is sensitive, clear, and supportive.
Pain and Symptom Management
Assess and safely manage pain, dyspnea, nausea and vomiting, constipation, anxiety, and depression.
Conducting a comprehensive pain assessment to guide safe and effective treatment.
Integrating routine risk assessment for substance use disorder when considering or using opioid therapy.
Designing a safe and effective opioid trial for the patient with serious illness.
Ongoing evaluation of opioid benefits, risks, and side effects for the patient with serious illness.
Safe opioid prescribing for patients with serious illness, using the Federation of State Medical Boards (FSMB) Guidelines for the Chronic Use of Opioid Analgesics.
Opioid pocket reference for providers including safe starting doses, equianalgesic chart, and standard dosing strengths. Center to Advance Palliative Care, 2019.
Training curriculum and clinical tools for assessing and managing five common symptoms in patients living with serious illness.
Collaborating with Palliative Care Teams
Know how to describe palliative care to patients and families and when to refer.
Defining palliative care, which patients need it, how it is delivered, and how palliative care differs from hospice.
Checklist of triggers for referral to a specialty palliative care team.
Searchable directory of specialty palliative care providers, filtered by care setting.
Best Practice Models
Case studies and guidance for improving symptom management and achieving goal-concordant care.
Recommended clinician training to improve on OCM measures.
Use of screening to risk-stratify patients for palliative care based on need. CAPC and the Accountable Care Learning Collaborative.
Integration of patient-reported outcomes (PROs) into the routine care of patients with metastatic cancer is associated with increased survival compared with usual care. Basch, et. al. JAMA 2017.
Patients with advanced cancer randomized to receive outpatient specialty palliative care lived longer and had better quality of life. Hoerger, et. al. Annals of Behavioral Medicine, September 2018.
Diane E. Meier, MD, FACP, FAAHPM
Director, Center to Advance Palliative Care
Allison Silvers, MBA
Vice President, Payment and Policy
Brynn Bowman, MPA
Chief Strategy Officer
Claire Ankuda, MD, MPH
Assistant Professor, Geriatrics and Palliative Medicine
The Mount Sinai Hospital