Death is not a pleasant subject, but in terms of medical care, it’s an important one – and appropriate home-based treatment for end-of-life cancer patients, rather than wasteful in-hospital expenditure, should be prioritised in South Africa argue oncology specialists.
The Independent Clinical Oncology Network (ICON) has announced a new programme to help cancer patients who have reached the end of anti-cancer treatment to access better end-of-life care through their medical aid.
The move will effectively put the money that would have been spent on unnecessary treatment and long stays in hospital towards supportive care that allows patients to die with greater dignity and comfort at home.
At present, many medical aids have provided only limited funds to manage terminal cancer patients who wish to spend their last days at home rather than in hospitals. This has resulted in high costs for end-of-life cancer care, says Dr David Eedes, Clinical Oncology Advisor at ICON. The organisation, which liaises between cancer specialists and their patients and the funders (medical aids), is encouraging the medical schemes contracted to it to make reasonable amounts of funds available for cancer patients requiring home-based care.
Dubbed the Best Supportive Care Programme, this initiative will take a more realistic look at palliative care, prioritising appropriate home-based treatment rather than wasteful in-hospital expenditure.
Palliative care has been described as “severely neglected” in South Africa, and Eedes says lack of funding is a key factor. This pressure, he believes, could be greatly relieved if funds were used more effectively.
“International studies show that a large portion of costs are for care in acute facilities, and the lion’s share of expenditure tends to be in the last few months of a cancer patient’s life,” says Eedes. A Canadian report notes that ‘the sickest 10% … account for close to 60% of programme spending; and about 30% of all health care costs for those age 65 and over occur during the last year of life’.
Effective palliative care, notes the same study, can significantly reduce healthcare costs; it’s also associated with improved patient and caregiver satisfaction, better symptom control and a greater likelihood of the patient dying in their preferred environment. In Spain, similar monitoring revealed that more effective palliative care saved the country millions of Euros each year.
“Controlling or reducing the cost of palliative care by supporting a home-based approach could therefore benefit the health care system, families and individuals [and] relieve pressure on health care resources,” says Eedes.
Further research has argued that technological advancements – and the associated increase in life expectancy – have meant that some patients simply live longer with the burden of disease; palliative or supportive care, on the other hand, helps to preserve dignity and quality of life.
One complication, argues Eedes, is that for many facilities and medical schemes, palliative care is understood to be necessary only when death is imminent. But ICON believes that, funding for such care should begin earlier. Once a patient is diagnosed with an incurable cancer the discussion about palliative care should start. When the time comes to stop anti-cancer treatments and concentrate on quality of life, the patient and family should be prepared and ready to go onto a programme like Best Supportive Care.
“We are encouraging medical schemes to offer more comprehensive financial support not only in terms of appropriate pain treatment but also all the other aspects of palliative care, with the aim to manage patients at home – the environment they are comfortable in,” he says.
Apart from giving patients more dignity, more contact with loved ones and better quality of life, ICON believes appropriately managed home-based palliative care will also cost medical schemes less. Earlier this year the The World Health Organisation (WHO) said that the fees charged by South African private hospitals are among the highest in the world, on par with countries including Germany, the UK, and France. Yet many patients end up dying in hospital because home care is either not funded or not available.
The early discussion about appropriate palliative care is a “difficult but important” one for the doctor, the patient and the family, Eedes noted at the recent ICON Conference, where the Best Supportive Care Programme was launched. Citing examples where poor communication left patients and loved ones alike “angry, unsatisfied and [feeling] short-changed”, Eedes argues for a more realistic approach toward terminal illness. The outcome after appropriate terminal care, he added, had a better chance of leaving families “sad but satisfied”, and able to treasure the good times – remembering a patient who died in a dignified way.
Best Supportive Care, Eedes explained, would form part of the broader picture of cancer care. It would be an active intervention, usually on the advice of the oncologist or GP but always with the patient and family consulted and involved in this decision. The main aims would be the alleviation of symptoms and improving quality of life and would not include anti-cancer treatment.
Many challenges need to be overcome to ensure this programme is successful, said Eedes. These included the early buy-in from the ICON doctors as well as the funders. The setting up of functional palliative support networks nationally, especially in under-resourced areas, will be crucial.
ICON, under its umbrella organisation ISIMO, is looking at ways to operationalise this programme so that a start can be made in 2017.
