How importance of palliative care in lung cancer patient? Phichai Chansriwong, MD Ramathibodi Hospital, Mahidol University

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1 How importance of palliative care in lung cancer patient? Phichai Chansriwong, MD Ramathibodi Hospital, Mahidol University

2 Outline 1. What is palliative care? 2. Palliative care and Lung cancer : A PERFECT MATCH? 3. Who should be treated with PC? 4. When to integrated palliative care? 5. Hospital based palliative care: 3 Main arguments 6. Good death

3 Palliative care is whole person care Palliative care VS Hospice care Palliative care Pallium Hospice hospes hospitium Hospice (curative treatment) VS Palliative care Curative treatment Humanized medicine 2/7/2018 3

WHO Definition of Palliative Care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through

4 WHO Definition of Palliative Care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

5 Palliative Care Consult: Three Parts

6 Who should be treated with PC? End- - 1 Cancer and non- cancer

7 Palliative care and Lung cancer: A PERFECT MATCH? Chronic, life-limiting, and highly morbid illnesses But the time will come when breathing becomes not only difficult but painful. The only thing they will be able to do for me is prescribe pain killers or put me on an oxygen mask. There will be absolutely no quality of life.

8 There are also distinct differences between the disease trajectory of cancer and common non-cancer diseases When to start palliative care?

9 Palliative care and curative care The old concept: 2 ways of the journey for the patient Palliative care Disease-focused Care ( Aggressive Care )

10 The wrong concept: Palliative care in a sense meaning palliative therapies without curative intent, when no cure can be expected (as often happens in late-stage cancers).

11 Integrated palliative care in every phase

12 Early integrated palliative care 2/7/

13 Early palliative care : better quality of life, mean score FACT-L 98.0 vs. 91.5; P=0.03). Improve depressive symptoms (16% vs. 38%, P=0.01). Median survival was longer (11.6 vs. 8.9 months, P=0.02). n engl j med 363;8 nejm.org august 19, 2010

Tangsujaritvijit V, Ngamphaiboon N, Reungwetwattana T, Chaiviboontham S, Konmun J, Sachdev

14 Mahidol University Wisdom of the Land An Impact of Early Palliative Care on End of Life Care in Advanced Non-Small Cell Lung Cancer Patients Chanprasertpinyo W,Semsarn S, Tangsujaritvijit V, Ngamphaiboon N, Reungwetwattana T, Chaiviboontham S, Konmun J, Sachdev V, Chansriwong P Department of Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University

Early palliative care group 4 weeks & before Rx

bereavement f/u Specialized palliative care doctors

performance scale (PPS) Edmonton symptom assessment

Perception of the illness and prognosis Benefits

Provided knowledge about the disease, Rx,self care

15 Early palliative care group 4 weeks & before Rx Monthly F/U at OPD or phone until death & bereavement f/u Specialized palliative care doctors and nurses initial consultation Palliative performance scale (PPS) Edmonton symptom assessment system(esas) Assessment patients & families about Perception of the illness and prognosis Benefits and side effects of anti-cancer treatment. Provided knowledge about the disease, Rx,self care Advance care plan discussion ETT CPR Inotrope Place of death Living will documentation

16 Primary outcome

17 Secondary outcomes

18 Secondary outcomes

20 Study Design

22 Eligibility Criteria Presented By Jennifer Temel at 2016 ASCO Annual Meeting

23 Cancer Type Presented By Jennifer Temel at 2016 ASCO Annual Meeting

24 Trajectory of Quality of Life Presented By Jennifer Temel at 2016 ASCO Annual Meeting

25 Trajectory of Depression Symptoms Presented By Jennifer Temel at 2016 ASCO Annual Meeting

26 The intervention led to improvement in caregivers total distress (HADS )in caregivers outcomes. THEONCOLOGIST 2017;22:

32 Hospital based palliative care: 3 Main arguments 1. Clinical quality, reduced distress symptoms 2. patient and family preference 3. Financial

34 Symptom Prevalence Pain Fatigue Constipation Dyspnea Nausea Vomiting Delirium Depression/suffering 80-90% 75-90% 70% 60% 50-60% 30% 30-90% 40-60%

36 Assessment EXPECTATION IDEA FUNCTION FEELING

38 Approach to Symptom Good assessment (ESAS/PPS/KPS) Re-assessments Multidisciplinary team approach Around the clock medication for continuous symptoms Not forget the Breakthrough medication Symptoms diary Palliative care consult in uncertain, not responding or difficult to control cases

39 Symptoms management Wiffen PJ, McQuay HJ. Oral morphine for cancer pain. Cochrane Database Syst Rev 2007 Oct 17 Quigley C. Hydromorphone for acute and chronic pain. Cochrane Database Syst Rev 2009 Reid CM. Oxycodone for cancer-related pain: meta-analysis of randomized controlled trials. Arch Intern Med 2006 Apr 24;166(8): Nicholson AB. Methadone for cancer pain. Cochrane Database Syst Rev 2007 Oct 17 McNicol E. NSAIDS or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database Syst Rev 2005 Jan 25; Wong R. Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database Syst Rev 2002 Bauman G. Radiopharmaceuticals for the palliation of painful bone metastasis-a systemic review. Radiother Oncol 2005 Jun;75(3):258-70

Ben-Aharon I. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008 May 10;26(14):2396-404 Uronis HE.

Br J Cancer 2008 Jan 29;98(2):294-9 Cranston JM. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev 2008 Jul 16;(3) Ben-Aharon I.

40 Ben-Aharon I. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008 May 10;26(14): Uronis HE. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer 2008 Jan 29;98(2):294-9 Cranston JM. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev 2008 Jul 16;(3) Ben-Aharon I. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008 May 10;26(14): Shaw P. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev 2004;(1)

43 Hospital based palliative care: 3 Main arguments 1. Clinical quality, reduced distress symptoms 2. Patient and family preference 3. Financial

44 Palliative do the concordance of Patients and family wishes What is the impact of serious illness on patients and family What do persons with serious illness say they want from our healthcare system?

46 Hospital based palliative care: 3 Main arguments 1. Clinical quality, reduced distress symptoms 2. patient and family preference 3. Financial

47 Palliative is imperative care

48 Fiscal imperative

49 Good death The truth is, once you learn how to die, you learn how to live. Mitch Albom, Tuesdays with Morrie Institute of Medicine report published 19 years ago, a good death is one that is free from avoidable distress and suffering for patient, family, and caregivers, in general accord with the patient s and family s wishes, and reasonably consistent with clinical, cultural, and ethical standards.

50 A good death is possible How to die well 1. Experience as little pain as possible. 2. Recognize and resolve interpersonal conflicts. 3. Satisfy any remaining wishes that are consistent with their present condition. 4. Review their life to find meaning. 5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire. 6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit. 7. Decide how social and how alert they want to be. CHARLES GARFIELD Great good magazine APRIL 30, 2014

52 Conclusion: Palliative Care - No for

53 Slide 31 Presented By Cardinale Smith at 2017 ASCO Annual Meeting

What is palliative care? What is palliative care? Dr Claire L Hookey

What is palliative care? What is palliative care? Dr Claire L Hookey Palliative Care an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening