The role of medical social worker in palliative care A study on early assessment and intervention

Transcription

1 醫務社工在紓緩治療中的角色 : 一項早期評估和介入的研究 The role of medical social worker in palliative care A study on early assessment and intervention 林泰忠醫生香港大學李嘉誠醫學院臨床腫瘤科臨床助理教授 Dr Lam Tai-Chung Clinical Assistant Professor, Clinical Oncology Li Ka Shing Faculty of Medicine, HKU

2 The need of patients with advanced cancer Oncological Service Anti-cancer treatment is improving rapidly Survival of late stage cancer patients has markedly prolonged in many types of cancer Treatment complexity and cost have also increased The stress on patients and their caregivers can be enormous Shortage of health care worker is a global phenomenon Palliative Care WHO: Palliative care is an essential part of cancer control Improves quality of life of patients and families facing life threatening illness Addresses physical, psychological, social and spiritual pain

3 Palliative care = end-of-life care? Anti-cancer treatment Palliative care Bereav e-ment Diagnosis of late stage cancer Physical Symptoms Palliative care referral Death Psychological Stress Care-givers burden Hospitalizations

4 The limitation of traditional Palliative Care Model Prolonged phase of anti-cancer treatment may cause overaggressive treatment at end-of-life period Chronic stress on patients and their caregivers causing burnout Poorly controlled symptoms during the early stage of disease Underuse of effective palliative care interventions, including symptoms control, counseling, family therapies or advanced care planning Misunderstanding that palliative care service referral must be done after exhaustion of anti-cancer treatments Relatively low coverage of palliative care service

5 Integration of palliative care and oncology service Cancer Treatment Tumor control, prolong life Supportive care relieve symptoms, support families, ACP Palliative Care Bereavement Diagnosis of late stage cancer Death Early palliative care referral o o No conflicts between palliative care and anticancer treatment. Both can be provided at the same time Early palliative care avoids overtreatment, improves quality of life, decreases depression and possibly prolongs survival

6 Integration of palliative care and oncology service: medical evidence Randomized controlled trials 1. Gade, G et al - Journal of Palliative Medicine Temel, J et al New England Journal Medicine Zimmermann, C et al Lancet Bakitas, et al Journal of Clinical Oncology Basch et al JAMA 2017

7 Early integration of palliative care into oncology service: Summary of clinical trials Studies Recruitment Intervention Outcome Gade 2008 Colorado, USA Inpatient palliative care consultation Temel 2010 Zimmermann 2014 Bakitas, 2015 Massachusetts, USA Ontario, Canada New England, USA Palliative Care Specialist clinic Palliative care clinic & nurse phone follow-up, community services 4-week course by nurses, monthly phone follow-up Lower cost, better satisfaction to health care team. Same symptoms, QoL and survival Improved quality of life (QoL) less depression, improved survival Improved quality of life and symptom control Improved QoL, less depression, improved survival Basch 2017 Carolina and NY, USA Weekly web-based selfreports of symptoms and rapid response by nurses Better QoL, less AED visits and hospitalization. Improved survival

8 Overall Survival Gain by the 71 drugs approved by FDA from 2002 to 2014 for metastatic solid cancers Basch et al: 5.2 months; Temel et al: 2.7 months; Bakitas: 5.5 months T. Fojo et al. JAMA Otolaryngology Head & Neck Surgery 2014 (140), 1225

9 The Model of Hong Kong Seven public clinical oncology centers One-stop service integrating palliative care and oncology service Multidisciplinary palliative care team Palliative medicine diploma training for clinical oncologists PRCC training for nursing specialists

10 2015 Palliative Care Outcome Review Hong Kong West Cluster Overall (n=307) Integrated palliation - oncology model (n=151) Usual practice of palliative care referral (n=156) P value Palliative care service coverage, n (%) 135 (44.0) 104 (68.9) 31 (19.9) <0.001 Median time from first contact of palliative care service to death, days Median time from last intravenous chemotherapy to death, days Use of strong opioid in the last 30 days of life, n (%) Cardiopulmonary resuscitation at end-of-life period, n (%) Intensive care unit admission in the last 30 days of life, n (%) Length of last admission including stay in acute ward and hospice, days Place of death in designated palliative care bed or hospice, n (%) 55 (19-153) 65 ( ) 24 (7 41) < (26 211) 81 ( ) 54 ( ) (39.7) 77 (51.0) 45 (28.9) < (2.0) 1 (0.66) 5 (3.2) (2.9) 1 (0.66) 8 (5.13) (13-47) 26 (13 47) 29.5 ( ) (28.7) 55 (36.4) 33 (21.2) Lam PL, Lam TC, AWM Lee. Supp Care Cancer 2017

11 Highly efficient The Model of Hong Kong: Strength and Limitations Clinical oncologists with palliative care diploma: 44 out of total 150 Oncologists to doctor ratio: ~30% of USA Coverage of palliative care is still not early enough average was ~60days before death Last admission length up to 28 days last month of life of patients was hospitalized! The urgent need to strengthen home care service and networking with community resources Very low rate of home death (<1%)

12 The role of social worker in palliative care Psychosocial assessment Counseling, psychotherapy, family therapy Care coordination and resources navigation Crisis management Advanced care planning Grief and bereavement Education and empowerment.. more innovation to come

13 Proposed pilot study: Social Worker-led early screening program Supported by LKSF Systemic recruitment of all advanced stage cancer patients Social Worker-led early screening Program Screening for the need of patients and their caregivers with Standard questionnaire sets Tailored interventions Regular review and monitoring Structured interview

14 Screening Program - Recruitment New case clinic Chemo Clinic Follow-up Clinic Social Workerled Early screening Program Hong Kong West Cluster Clinical Oncology Center at Queen Mary Hospital receives ~3000 new cancer patients per year. About half of these were in advanced stage Patients may develop recurrence and metastases during follow-up Recruitment would need to collaboration of all frontline doctors and nurses

15 Screening Program Assessment Tools Disease understanding, acceptance and coping Physical symptoms and QoL: McGill QoL - HK Psychology: PHQ-9 (depression), GAD-7 (anxiety) Spirituality: demoralization and suicidal risk Modified caregiver strain index Social support and financial status assessment

16 Screening Program Tailored intervention High-need patients and care-givers Physical symptoms: early reassessment clinic appointment Psychology: counseling, psychologist referral Coping skills: patient support group Social resources referral and networking Spiritual and existential distress: Chaplaincy referral Goal of care alignment: family and clinician conference Crisis management: Prompt referral to palliative care MDT intervention

17 Regular monitoring for Low need patients and care-givers Web / app based monitoring Pain score monitoring Once per week for patients on strong opioid Once every 2 weeks for others E-reminder for drug adherance Overall quality of life monitoring McGill quality of life HK Version (16 items) Rapid-response system: if symptom score or distress increase consecutively for 2 weeks, prompt alert system for early clinic assessment Social worker face-to-face review every 6 months if remained stable

18 Proposed model: MSW early screening Program New case clinic Chemo Clinic Follow-up Clinic Social Worker led Early screening Program Screening tools: 1. Disease understanding and acceptance 2. McGill QoL - HK 3. PHQ-9 (depression) 4. GAD-7(anxiety) 5. Coping skills 6. Caregiver strain index 7. Financial assessment 8. Demoralization / suicidal ideation Low need: App-based continuous assessment Q6 months review at MSW clinic High need: 1. Physical track: Pain / ESAS score high early referral to clinics 2. Depression / anxiety / suicidal ideation Counseling / CP referral 3. Coping skills improvement: group therapy 4. Family conference / counseling 5. Chaplaincy referral for demoralization 6. Financial assessment / social resources mobilization

19 Palliative care strategic Framework Enhance governance by developing Clusterbased services with the collaboration of medical and oncology palliative care specialists 2. Promote collaboration between palliative care and non-palliative care specialists through shared care model according to patients needs 3. Enhance palliative care in the ambulatory and community settings to support patients and reduce unnecessary hospitalisation 4. Strengthen performance monitoring for continuous quality improvement

20 Future service model of adult palliative care in HA

21 Summary Concrete evidence suggests the benefit of early integration of palliative care into oncology practice: the question is how to implement this in our local settings LKSF supported palliative care and hospice service has set an effective care model of palliative care in the past 10 years The proposed social worker-led screening clinic will be a pilot study to explore the effectiveness of a personalized, needbased palliative care service model

22 Dame Cicely Saunders ( ) A nurse, social worker ( ) and physician The founder of modern hospice care Social workers are always the key leaders in palliative care movement!

23 Acknowledgement HA HKWC QMH Clinical Oncology team HA HKWC Department of medical social work HKU Department of Clinical Oncology HKU Faculty of Social Science HKU School of Public Health Li Ka Shing Foundation