Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

The 2002 Circle of Life Award

This issue of Innovations features Project Safe Conduct, a model of interagency collaboration to improve care and services for patients dying of lung cancer and their families. Staff at Hospice of the Western Reserve, a large community-based hospice in Cleveland, Ohio, and Ireland Cancer Center (University Hospitals of Cleveland/Case Western Reserve University), a National Cancer Institute comprehensive cancer center, worked together to create and sustain an interdisciplinary palliative care team based at the cancer center. One of the most unusual aspects of Project Safe Conduct is that staff from these culturally distinct institutions got together and decided to supplant the traditional "either/or" approach (pursue cure-oriented treatment or access palliative care and/or hospice ) with a mixed model of services at Ireland Cancer Center that would enable patients with advanced lung cancer to continue aggressive treatment and receive palliative care at the same time.

Project Safe Conduct was chosen to receive a 2002 Circle of Life Award. The award, now in its third year, is sponsored by the American Hospital Association (AHA) in conjunction with the American Medical Association, the American Association of Homes and Services for the Aging, and the National Hospice and Palliative Care Organization, and is supported by a grant from The Robert Wood Johnson Foundation. This year's award will be presented July 26, 2002 at the Health Forum Summit in San Diego, California.

For the past two years, Innovations has developed theme-based issues in conjunction with each winner of the Circle of Life Award. See the Archives page to explore the work of past winners in depth.

Project Safe Conduct is one of four institutions to be honored with this year's Circle of Life Award. Click on the name of the institution below for a summary of each program, drawn from the Executive Summary and other materials each submitted to the AHA as part of their application for the award:

• Project Safe Conduct at Ireland Cancer Center
• Hospice of the Bluegrass
• Children's Hospital and Health Center San Diego
• Population-based Palliative Care Research Network (PoPCRN)

• Mount Carmel Health Hospice and Palliative Care Program, Columbus, Ohio
• Parkland Health System, Dallas, Texas
• Rehoboth McKinley Christian Health Services Hospice, Gallup, New Mexico

To read more about the award, or apply for next year's award, visit the AHA page devoted to it.

The editorial in this issue is authored by Thomas Smith, MD, an oncologist and palliative care leader at Virginia Commonwealth University. In his editorial, Dr. Smith describes the challenges facing those seeking to establish palliative care within cancer care institutions, in particular, the need to evaluate the program in ways that will convince the leadership of these institutions that the new practices are "worth it," as measured in terms of cost/benefit analysis and clinical efficacy. He urges innovators to use the "gold standard" of cancer research—the randomized controlled trial—to establish whether or not such programs such as Project Safe Conduct are making a measurable difference in patients' quality of care and quality of life, and therefore merit a cancer center's long-term commitment of resources and staff.

When studying the impact of complex systems change, a variety of methods are helpful in understanding both processes and outcomes. The Project Safe Conduct researchers collected a range of pre and post-intervention data, and administered a battery of established psychosocial measures to track dimensions of patient and family experience and so evaluate the impact of their intervention. Pre- and post-intervention data are powerfully suggestive, when the intervention, as in this case of Project Safe Conduct, includes almost the entire population of patients with advanced cancer for a period of two years (233 patients of a total pool of 239 participated.)¹ Evaluation designs other than RCTs clearly have their place, particularly in emerging fields. In recent years, quality improvement techniques² and a whole range of measurement tools have been developed and applied to end-of-life care, in an effort to measure changes in outcomes.³ Ideally, to really pinpoint what is responsible for an improved outcome, one should have a randomized control group. However, it can be extremely challenging to implement a controlled study within one institution, as staff educational efforts "contaminate" both groups, and often make it hard to establish significant differences.⁴

A Personal Reflection from Dr. Timothy Gilligan, an oncologist working at Dana-Farber Cancer Institute, a comprehensive cancer center located in Boston, Massachusetts, explores the role of the oncologist in relation to the palliative care team in helping patients with advanced cancer maintain and reframe their hope as the disease progresses and life-prolonging options dwindle. His essay provides perspective on how individual clinicians and patients, who have been partners in fighting the cancer, make the transition from a primary focus on seeking a cure or prolonging life to a primary focus on ensuring comfort and facilitating closure.

We invite readers to discuss the issues involved in implementing and sustaining a mixed model of life-prolonging treatment and palliative care in a cancer care setting through the online discussion web board for this issue. Elizabeth Ford Pitorak MSN, APRN, CHPN, former project director of Project Safe Conduct will be our online guest for two weeks following posting of this issue.

References:

1. Pitorak EF, Armour M, Sivec H. Project Safe Conduct integrates palliative goals into comprehensive cancer care. Innovations in End-of-Life Care. 2002;4(4) www.edc.org/lastacts [Return to Notes from the Editor]

2. Lynn J, Schuster JL, Kabcenell A. Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians. New York: Oxford University Press, 2000. [Return to Notes from the Editor]

3. Toolkit of Instruments to Measure End-of-Life Care at www.chcr.brown.edu/pcoc/toolkit.htm [Return to Notes from the Editor]

4. Bookbinder M, Romer AL. Raising the standard of care for imminently dying patients using quality improvement: An interview with Marilyn Bookbinder. Innovations in End-of-Life Care. 2001;3(4), www.edc.org/lastacts [Return to Notes from the Editor]