Table 4.

Barriers to Palliative Care by Oncologist Type

Oncologist Type	Comment
Hematologic malignancy
Treatment goal	“If she's responding to treatment and she wants to be aggressive to treatment; if she's totally asymptomatic and doing well and stable, I would not refer her.”
Treatment goals as barrier (eg, preference for clinical trials instead, need for transfusions, expected benefit from ongoing treatment)	“If she said, ′I want to do everything I can, give me the medicine. I don't care, I'm tough, I can take it.' Then, I would be less likely to refer her.”
	“So, we would have all the options available and sometimes there is a new drug in clinical trial at another institution…. So we have been referring two to three patients per month to other clinics from our center because we felt like that treatment option … the patient should have an opportunity to try that. And not be sitting and discussing palliative care with me.”
Control/distrust	“Well, that's kind of what we do. This is the bread and butter for what oncology does. We try to actually treat their symptoms and take ′em though death and dying, the process of death and dying. And I think the services that we are able to provide are pretty good.”
Distrust of others and their oncologic knowledge	“I rarely find a situation where I think an outside person can be useful—except sometimes in helping to control chronic, severe pain—which patients with hematological malignancies, fortunately, rarely have in the terminal part of their illness…. I guess I have the sense that that's part of my job.”
Preference to maintain control/not wanting to bring in another party	“I think the bias and the reluctance is sometimes that the team comes and kind of takes over and writes orders without really acting as a consultant, but really as … you know, kind of … as I said, kind of takes over. And I don't think a lot of referring physicians really like that.”
History of conflict or prior negative experiences with palliative care	“At the beginning when palliative care was started and everything, we had some issues about palliative care physicians coming to … just to go ahead and discuss DNR without, you know … approaching us in that regard.”
It's just different	“Well, in hematologic malignancies—which is what I specialize in—and it's very different from solid oncology. Patients will respond to a lot of available treatments. And so, they can continue to have a good quality of life while getting chemotherapy, even though they may not be curative candidates. And so we treat them based on understanding … based on their wishes or … until we know that there's nothing else that we can give them. And usually at that point, we decide that this is the end of the road. The problem is, at that point, they usually are very sick. So, a lot of the times, it's a matter of days before the patient will expire. So, if they don't … and they don't necessarily want any involvement by palliative care services. If we think that they have more than a day or two, then we can do that.”
Hematologic oncologists deal with unique set of disease characteristics that make palliative care either more difficult to apply or seemingly inappropriate	“And so, it … I think in the past, when I've been interviewed on this topic, or talked to people about this topic, palliative care in general, the problem is … there's some overlap, but the problems by and large are a little different for hematological malignancy and bone marrow transplant patients than they are for solid tumor patients. And that … their terminal care is often different than for solid tumor patients.”
	“As you can tell, I'm very … this is a point of major contention for me. I really find it very difficult, because our patients are all heme malignancy patients and I think we shouldn't have to choose between transfusing or hospice.”
Solid tumor
Practical barriers	“I guess, like I said, the biggest thing we'd like to see is more time; that they're available…. I don't think there's quite enough people, personnel or slots.”
Practical issues as barriers (palliative care clinic accessibility and capacity, reimbursement, insurance, awareness of services)	“Also, the patients I have referred to symptom management service, they're … they've not been that helpful. They don't give timely appointments. They give an appointment like maybe six weeks, which is useless…. In an emergency situation, we cannot reach them or they are unavailable, they don't have appointments, and it's not been a user-friendly situation.”
	“They also don't accept any outpatient insurance. So we order a lot of inpatient palliative care consults because that's where most of the investment has been made in palliative care, but there are very few outpatient visits because there's no availability in the outpatient setting.”

Abbreviation: DNR, do not resuscitate.