Care towards the end of life

Transcription

1 Care towards the end of life Andrew M. Wardley The Christie Hospital Manchester Cancer

2 What is your preference?

3 What is your preference?

4 The death of the NHS

5 1 st Consultant post

6 A few issues 3 hospitals 2 multi-disciplinary team meetings 6 clinics Complex issues Little support Inpatients Neutropaenic Complex care needs

7 Modus operando 2001 Patients with advancing disease often continued active treatment Discussions around future care would often occur late on in the disease trajectory Reactive approach when problems arose Crisis intervention in clinic Limited supportive care/community involvement Often result in emergency admissions

8 Phone a friend Involvement of palliative supportive care early ABC multi-disciplinary team meeting Breast care nurses Research team Specialist in palliative medicine Streamline clinics Neo/adjuvant Metastatic breast cancer Research

9 2008 new drivers NCEPOD End for life Strategy Gold Standard Framework (GSF) Preferred Priorities for Care (PPC)? 3 rd line chemotherapy if progression no benefit of 2 lines

10 Evolution New post focussed on End of Life Care Joint funded Breast Medical Oncology A change in practice which has evolved over time.

11 Practice Progressing disease identified MULTI-DISCIPLINARY TEAM MEETING Treatment including trial options are discussed Holistic needs assessment questionnaire (SPARC) Involvement of Palliative Care if appropriate Identify & address concerns Plan for their future care including PPC Community links - likely prognosis of the patient

12 Working across the whole breast disease group Helping clinicians identify patients with advancing disease Teaching Supporting and guiding clinicians, BCN s Being proactive within out patients Integrating Holistic Needs Assessments for patients with advancing disease.

13 Macmillan breast palliative care project Increase communication with community teams Increase Advance Care Planning discussions Integrate of Supportive Care in the whole group Support transition from chemotherapy to Supportive care Early-phase clinical trial

14 Benefits of earlier supportive and palliative care Improves patients quality of life Reduces the need for aggressive interventions in the last days / weeks of life Can help to optimise the use of chemotherapy in advanced cancer Has the potential to improve survival 1. ( Early Palliative Care for Patients with Metastatic Non Small-Cell Lung Cancer, Temel JS et al, N Engl J Med 2010; 363: August 19, 2010). 2. Palliative and Supportive Care: Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial - Marie A. Bakitas, Journal of Clinical Oncology May 1, 2015: ; published online on March 23, 2015; DOI: /JCO Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non Small-Cell Lung Cancer; Joseph A. Greer, JCO; Feb , vol 30, no 4, )

15 ENABLE III Early vs Delayed Palliative Oncology Care 207 patients Randomised to receive Palliative care at study enrolment (early) Versus 3 months later (delayed) 1-year survival rates were 63% in the early group and 48% in the delayed group (P = 0.038)

16 CQUIN : Patients with advanced progressing cancer

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18 4 disease groups Breast SYMPTOMS Upper GI CONSULTATIONS Skin / Melanoma COMMUNICATION HPB

19 Audit results clinical standards

20 The discussion confirmed what I thought I knew but I was told in a positive way that has allowed me to live with this information, even though it is disastrous As long as I know the facts then I am ok. It has given me hope. It reassured me in a positive way something can be done. Life expectancy was discussed with me; I was pleased I understood the situation. It helps me as long as people are honest. I like to think I have a positive outlook.

21 Additional cost benefits: Proactive supportive care Less need for hospital admissions Reduction in length of stay Fewer intensive care hospital days Lower overall healthcare costs 1. Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives, December 2012, Association for Palliative Medicine GB & Ireland, Marie Curie Cancer Centre, National Council for Palliative Care, Royal Society of Medicine 2. Smith TJ et al., Cost and non-clinical outcomes of palliative care. J Pain Symptom Manage. 2009;38(1): Save bed days, Reduce re-admission rates and Improve Quality of Care: The benefits to trusts in adopting national end of life care tools,, Spreading the Winning Principles Case Study, NHS Improvement, 2009

22 Increasing activity

23 More systemic anti-cancer therapy

24 SACT by line

25 SACT PS 2

26 30 day mortality

27 Breast 30 day mortality

28 Reduced emergencies

29 How does this compare SACT vs 30 day mortality

30 Enhanced supportive care 1. Earlier involvement 2. teams that work together 3. A more positive approach to supportive care 4. Cutting-edge and evidence-based practice in supportive and palliative care 5. Technology to improve communication 6. Best practice in SACT

31 Next steps National cquin Breast Medical Oncology/ECMT links Vanguard opportunities Manchester Cancer Hospice development? Outreach?

32 Work smarter not longer With thanks to Tracey Coleby Anne Armstrong Sacha Howell Richard Berman Catherine O Hara Ruth Swindell Liesl Hacker