Promoting Excellence : Integrating Cancer Care and Palliative Care : Memorial Sloan Kettering Cancer Center

"I am in the field of palliative care because of the day-to-day gratification of knowing I make a difference every day. Palliative care doesn’t save lives per se, but it can make a huge difference.”

--Richard Payne, MD

Institution
Memorial Sloan Kettering Cancer Center
New York, New York

Program
Pain and Palliative Care Service

Year Started
1975

Patients Seen
The service sees between 10 to 24 outpatients per day and 10 to 35 inpatients.

Director
Richard Payne, MD
212-639-8031
payner@mskcc.org

Program Mission and Objectives
Leadership through excellence

To excel at multidisciplinary patient care.
To excel at training future leaders and to serve as role models.
To excel at doing research.

Program Description
The Pain and Palliative Care Program sees patients who have cancer and allied diseases. The Pain and Palliative Care Program considers occasional requests to see patients with chronic pain, but not cancer, on a case-by-case basis. A physician or nurse refers patients to the program. The team includes physicians, nurses, a social worker, a grief and bereavement therapist and a pastoral counselor. Patients always see a fellow, nurse and attending physician; other referrals are made as needed.

The program encourages the patient’s family to participate, but ultimately, the level of participation is up to the patient. There are no formal programs for family other than bereavement services.

Historical Perspective
The Pain and Palliative Care Service has evolved over the past 25 years from a program based on the neurological study of pain to a program recognizing the broader implications of how cancer patients experience pain.

In the mid-1970s, Kathleen Foley, MD, and Raymond Houde, MD, began seeing patients with pain in the outpatient medical clinic. Foley then started an inpatient pain consultation service in the Department of Neurology; the founding chair supported her efforts. This program was called the Pain Service. A training program for fellows, an observership program and a research program began in the late 1970s.

In 1981, Memorial Sloan Kettering Cancer Center (MSKCC) developed the Supportive Care Program for patients at home. Initially, this program was supported by philanthropic funds. In 1985, the hospital assumed its funding. In 1996, the name of the Pain Service was changed to the Pain and Palliative Care Service, reflecting the fact that the service had broadened its mission to encompass additional physical symptoms including fatigue, depression and psychological distress, dyspnea, etc. In February 2000, the service opened an inpatient unit.

Research
The program is currently studying approximately eight protocols and four drugs/analgesic agents. Researchers are also looking at depression and will to live and just completed a pilot study of tools to measure quality of life in very sick outpatients.

Education
The Pain and Palliative Care Service trains three to six fellows each year and is the primary clinical site for Cornell medical students doing their two-week rotation in palliative care and ethics. The service also has an NIH-funded observership program and a nursing fellowship program.

Partnerships
Richard Payne and his colleagues have a grant to develop a palliative care program at North General Hospital. They also work on joint research projects with Beth Israel Hospital and Calvary Hospital.

Marketing
The service does fundraising but no marketing at this time.

Funding
The Pain and Palliative Care Service is funded by Hospital support (6%), foundation grants (25%), endowments (5%), and federal grants (5%).

Vision
Richard Payne’s long-term vision is to maintain the excellence this program has already achieved in clinical services and research. He would also like to develop two additional programs: a palliative care unit (and perhaps a hospice unit) and a rehabilitation unit as part of pain and symptom management. Cancer patients can have significant functional limitations from the disease or from therapy and are not necessarily treated optimally in conventional rehabilitation units.

A National Perspective
Elements and Measures of Program Success

Palliative care must be seen as a partner and integrated into primary disease management. Although palliative care will not be responsible for a cure, it is still critical to the battle against cancer.

If the institutional culture values research, palliative care programs must do it and do it well.
To be truly interdisciplinary, a palliative care program must have a plan for administering the program across traditional department lines.

Necessary Steps
For pain management and palliative care services to survive and thrive in academic institutions, they must establish and maintain the same high standards of patient care, teaching and research that all other services in an institution must meet. This will take leadership from national societies like the National Cancer Institute.

What I Wish I’d Known Then . . .

“I naively took for granted that other health care providers would see the logic and the need for what we do and therefore things would be easy. I wish I had been savvier about the professional and emotional barriers to integrating palliative care. After 20 and 30 years, there are still doctors who don’t get it. They think it’s an either-or situation—they can’t be a good surgeon, for example, and worry about pain, too.”

----Richard Payne, MD

This descriptive summary is based on an interview conducted by

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.