**5. Diverse models of PC delivery: existing trends and future opportunities**

When patients with lung cancer are admitted to the hospital, PC is traditionally provided by consultation teams in inpatient settings [24]. As PC can largely reduce hospital expenses, fee-for-service bundled payment systems have a large influence on the development of PC delivery models [25]. Specialist consultation services and inpatient PC facilities, in which the PC team members are the primary patient caregivers, are the two most common models in hospital settings. Consequently, PC is expected to be centered in inpatient settings in the USA [26, 27]. More recent models of PC include multidisciplinary clinics [2, 28–31], home- or communitybased care [32, 33], alternative delivery models (such as those that employ telephone and telehealth methods [7, 34, 35]), and outpatient PC clinics [36–38]. These newer

models are favored over traditional inpatient delivery models because the focus is on the upstream incorporation of PC in outpatient settings. Additionally, the care coordination and follow-up settings are better established [39]. Some of these newer PC delivery models are discussed in depth below.

#### **5.1 Multidisciplinary PC or oncology clinics**

Although the timing of PC introduction should be based on patients' needs, it is important that assessments include factors such as the patient's prognosis, time from diagnosis to median survival age (based on cancer stage), treatment trajectory (such as first or second line of treatment), and performance status [40]. Delivering PC to patients with lung cancer at the same time as their lung cancer treatment in outpatient oncology clinic settings is a well-established delivery model that has been found to improve patient outcomes [2, 28]. Similarly, breathlessness clinics also provide a multidisciplinary integrated service that often combines respiratory, physiotherapy, occupational therapy, and PC examinations and management as a one-stop treatment paradigm. Although it is not limited to patients with lung cancer, this approach has increased the patients' mastery of breathlessness (i.e., patients' feelings of control over their respiratory condition and its impact on their QoL and function) by 16% as compared with the control group [31]. Furthermore, a systematic evaluation of 37 research articles covering 18 different breathlessness services found a substantial reduction in distress due to lower breathlessness and depression ratings compared with the control groups [41]; however, no variations in the health status or QoL could be identified. PC integration in outpatient multidisciplinary settings could be the most effective model for coordinating the care of patients with lung cancer, particularly if they are also being given disease-directed treatments like radiation or chemotherapy. Nonetheless, there is a major shortage of PC professionals, as well as a lack of capacity in outpatient cancer settings at present, and these have been reported to be significant barriers hindering the widespread implementation of such approaches [26, 42, 43].

#### **5.2 Community-based PC**

The interdisciplinary community-based care offered by registered home health or hospice agencies may have influenced the development of this approach. Previous studies have shown that this model can enhance patient satisfaction, reduce care demands in emergency departments, reduce the number of hospital days, and minimize the number of skilled nursing facility days compared to administering PC in general care settings for those with serious illnesses, including approximately 61% with advanced cancer [44]. Moreover, healthcare costs dropped by 45% due to a reduction in the use of healthcare resources. In the future, community-based PC will likely become an increasingly important PC delivery model [33]. Nonetheless, evidence supporting the use of community-based PC for patients with lung cancer is limited.

#### **5.3 Telehealth**

Patients and their families, particularly those living in rural areas, have been advised to use delivery models that involve telephone and telehealth technologies to reduce travel demands. In the ENABLE trial, telephone-based assessments were employed to facilitate the delivery of PC in a rural population of patients with

#### *Palliative Care for Patients with Lung Cancer: A Review of the Current Developments… DOI: http://dx.doi.org/10.5772/intechopen.106797*

advanced cancer, and the results demonstrated improved QoL [2, 45]. Another study found that a nurse-led, completely telephone-based PC intervention for patients with lung cancer is feasible [35]. Although alternative PC delivery models will almost certainly include a combination of treatments (including telemedicine), existing evidence is limited to observational non-controlled research and a few quasi-experimental studies [46]. A more recent umbrella review revealed that there is still a lack of evidence to support the use of telemedicine techniques in PC [47].

Technological issues are a significant drawback of telehealth approaches, particularly when live video platforms are used. Commonly reported issues include poor connectivity and connection, slow video feed, or problems with understanding how to use the technology (particularly among older patients) [48]. These issues are more prominent among patients from lower socioeconomic groups, non-Caucasians, and those living in rural areas. Moreover, clinicians have reported that the most severely ill patients gained the least benefits from the telehealth symptom management options [49]. Thus, there is a significant research gap regarding the intersection of PC and telehealth. Nonetheless, several well-established innovative PC delivery models have been developed for patients with lung cancer. Inpatient delivery models are preferable for such patients due to the symptom burden and their frequent inpatient clinical encounters. However, research has shown that outpatient models also enable early PC integration and enhance patient outcomes. Thus, combined delivery methods based on available resources and context are critical in providing timely PC based on the guidelines proposed by the ASCO, which recommend that PC is initiated within 8 weeks of diagnosis of advanced lung cancer [1].

Based on the above, further research is required to determine the optimal methods for delivering PC to patients with advanced malignancies. The best approaches are likely to be multidisciplinary in nature and accessible to all patients in need. In order to understand the barriers hindering the universal provision of specialized PC to patients with advanced lung cancer, oncological care providers must be able to identify and address the needs of such patients as much as possible. Standard guidelines outlining the factors involved in PC (specifically in the field of oncology) have been put forward by the ASCO and the American Academy of Hospice and Palliative Medicine [50]. Experts agree that symptoms must be evaluated and managed, with a specific focus on common oncologic symptoms, such as pain, nausea, diarrhea, vomiting, and dyspnea.
