2012 AAHPM & HPNA Annual Assembly

Transcription

1 in the Last 2 Weeks of Life: When is it Appropriate? When is it Not Appropriate? Disclosure No relevant financial relationships to disclose AAHPM SIG Presentation Participants Eric Prommer, MD, FAAHPM Director Palliative Medicine, Mayo Clinic Hospital Mayo Clinic Arizona Thomas Smith, MD Director of Palliative Medicine, Johns Hopkins Medical Institutions Professor of Oncology, Sidney Kimmel Comprehensive Cancer Center Mary Buss, MD Palliative Care Consultation Service, Gynecology Oncology Program Beth Israel Deaconess Medical Center Sydney Dy, MD, MSc The Duffey Pain and Palliative Care Service Sidney Kimmel Comprehensive Cancer Center Johns Hopkins Medical Institutions Lynn Billing, RN, CHPN, BC The Duffey Pain and Palliative Care Service Sidney Kimmel Comprehensive Cancer Center The Johns Hopkins Hospital Introduction Concerns exist that the treatment of patients with advanced cancer is becoming increasingly aggressive near the end-of-life Quality indicators have been developed to measure and act as alerts for poor quality cancer care The use of chemotherapy near the end of life has been identified as a quality indicator of cancer care Case Presentation 67 y/o old man presents with adenocarcinoma of the lung, stage IV. Disease includes a pericardial effusion, and a pleural effusion. His ECOG PS is 2. The chance of cancer shrinking with single agent chemotherapy gemcitabine is about 10-20%, with another 10-20% having stable disease with at least 60% progressing. Best data in limited studies show that chemotherapy might extend his life by several weeks. The team is hesitant about chemotherapy due to side effects. The patient and his family are insistent on any treatment that might lengthen his life span, and are not interested in discussing hospice until he has had a trial of chemotherapy. The oncologist feels that chemotherapy should not be given. Questions How can clinicians help patients and families determine when further chemotherapy is no longer beneficial? How can clinicians help each other determine when further chemotherapy is no longer beneficial? 1

2 Indications for Palliative Improve disease-free or overall survival Relieve symptoms and/or improve quality of life ASCO 1996: could not identify specific benefit where chemotherapy could always recommended They recommended that outcomes must be balanced against toxicity and cost And there MUST be a DEFINABLE benefit before recommendation (not maybe ) Palliative Effects of (advanced disease) Tumor Symptom Survival Control/QOL Lung(1 st ) yes yes Lung(2 nd )* yes yes Lung(3 rd )* yes yes Breast(1 st, yes yes 2 nd, 3 rd ) Colon(1 st, yes yes 2 nd, 3 rd ) Prostate yes yes * One of these is erlotinib, targeted oral agent. Not 3 different usual chemotherapies. Smith 2008 Other Responsive Cancers Bladder/Germ cell tumors Ovarian Esophageal Gastric, colon Head and neck Hematologic malignancies Case Presentation Debby, 34 yr old professional, married, 9 month old daughter Presents with enlarged liver, abdominal mass, hypercalcemia, hyperbilirubinemia Confused, drowsy, distended d d abdomen, severe abdominal pain Pathology- adenocarcinoma, unknown primary Debby, continued Oncologist and Palliative Care talk outside the patient s room Good response to chemo, minimal side effects Quality time with family and friends, planned for daughter s future Died 3 days after her daughter s first birthday 2

3 Oncologist s Reasons for Giving Over-estimates prognosis Emotional attachment to patient Overlooks (non-physical) treatment burden Assumes patient wants chemo Fear of depriving patient of hope, chance for longer/better life Patient does share true feelings to cancer doctor Reasons Young patients (families, children) Previously untreated ( owe them a chance ) Patient wants to fight, wants chemo despite understanding probable negative outcome, and understands alternatives Data supports that chemo helps: Palliate symptoms Prolong life (to meet patient s goal) Nursing Perspective Witness suffering Moral distress Frustration How can they NOT see she is dying? Physically giving chemo while worrying about causing additional suffering Oncologist Reason 1. Emotional attachment 2. Over-estimate prognosis 3. Overlooks treatment burden 4. Assumes patient wants treatment 5. We are not trained in this, don t enjoy it, and it is painful for us PC Response 1. Validate emotion 2. Inquire of anticipated life expectancy of patient 3. I worry that chemo will make it harder for pt to... (achieve goal) 4. Pt shared some fears with me This is why many of us got into the field. Process for Guideline Development Conversation outside of the room vs. conversation inside id the room Working group, policy paper, fellow and bioethics involvement Review of existing guidelines, NCCN Integration into Cancer Center efficiency initiative, EOL workgroup, informed consent for chemotherapy pilot project Meetings with each disease group to review plan, develop guidelines, led by director of clinical practice 3

4 Key Principles Guidelines rather than requirement Not starting new regimens (second line, third line, etc.) rather than stopping ongoing chemotherapy Purpose is not to deny care, but to use Cancer Center resources rces more effectively el patients may seek care elsewhere Avoiding end of life chemo may improve survival, and accumulating evidence shows it does not help survival Disease-specific guidelines Integration of palliative care U S Oncology pathways preserve survival, reduce cost by 35% in lung cancer by evidence-based choices, better communication. Communication: Discussion of ADs, DPMA, hospice in first visits Generics Limit to 3 rounds of chemo Less chemo Less hospital More hospice 2x LOS, use This is part of a bundled payment program that does not give the Oncologist any reason to give end of life chemo, and encourages Conversations. U S Oncology pathways preserve survival, reduce cost by 34% in metastatic colon cancer. Involving PC early leads to less IV chemo in the last 60 days of life*, associated with better understanding of prognosis and treatment options**. And better survival.*** Hoverman R, et al. Am J Manag Care May;17 Suppl 5 Developing:SP Percent of NSCLC patients getting IV chemo *Greer JA et al. J Clin Oncol Dec 2011 epub **Temel J, et al. J Clin Onc Jun 2011 ***Temel J, et al. NEJM 2010 NSCLC patients who get chemo in the last 14 days of life live NO longer than those who do not. And entered hospice less (51% vs. 81%) and later. The National Guidelines already have transition rules based on evidence Percent of NSCLC patients getting IV chemo Saito AM, Landrum MB, Neville BA, Ayanian JZ, Earle CC. The effect on survival of continuing chemotherapy to near death. BMC Palliat Care Sep 21;10:14. 4

5 The National Guidelines already have transition rules based on evidence Guidelines Kimmel Cancer Center Morbidity and mortality conference: Cases of harmful EOL chemotherapy 28.5% of patients received chemotherapy in last 30 days of life: Few patients had documented or reported EOL discussions Recognition that end-of-life chemotherapy uses extensive Cancer Center resources, little benefit Agreement from faculty and staff that guidelines would be helpful Example: Transition from, Acute Care, and Palliative Care To Palliative Care Breast Cancer Transition is less traumatic if: Prognosis with metastatic breast cancer has been discussed at the initiation of treatment and when disease progresses and treatment changes Expectations from treatment regimens are specified, e.g. PFS, likelihood of meaningful benefit Importance of palliation stressed even when extending survival or slowing progression are still goals of treatment Example: Transition Guideline for Breast Cancer Rather than base the transition on some number of chemotherapy regimens received for metastatic breast cancer, e.g. 3, we believe it should be based on the patient s diminished health status, i.e. PS, expected survival. The transition should be recommended when the patient s health status is so diminished that the potential benefits of treatment are not worth the risk. In this way the transition guideline parallels eligibility for investigational therapy. Patients are eligible for additional therapy, investigational or standard, if PS is good regardless of number of previous regimens. Transition Guideline for Breast Cancer 1 st Line Standard may be recommended even if PS and prognosis are poor because breast cancer typically responds. In some very sick patients, however, even 1 st line chemotherapy should be avoided. Subsequent Standard, i.e. 2 nd line, 3 rd line, etc., or investigational therapy recommended until: PS 3 or PS 2 With rapidly progressing disease and expected survival < 3 months Other uncontrolled systemic disease, e.g. CHF, which may shorten survival and increase risk of lifethreatening complications from chemo How to Recommend Transition Remind the person that you have reached the point you had discussed earlier in the illness. Always ask What do you want to know? What do you know? Tell the person you do not recommend more chemotherapy because the chance of benefit is low, and the chance of side effects too high. List both for those who want numbers. Tell the person that this is the recommendation of ASCO and NCCN and. You can offer consultation elsewhere, but if ASCO AND NCCN agree. Time to enroll in hospice (which she met before) And you will still be her doctor. HELP with transitions by making recommendations hospice. Ask What is your understanding of what we have discussed? (ASK, TELL, ASK) 5

6 Approach to Patients Who Still Want Clearly establish with patient specific goals of chemotherapy and indications for stopping Discuss plan with all team members to assure that they know goals of chemo and indications for stopping Recommend Palliative Care consult so full range of patient and family needs can be addressed Next Steps Clear, concise chemotherapy consent form REQUIRE PER POLICY State the goal of the therapy: Curative Palliative (cancer will not be cured but may be controlled, focus on minimizing symptoms) At some point, your oncologist may recommend stopping chemotherapy and discuss options of ongoing care for you, such as hospice. The Palliative Care Service will be involved with your care How can Palliative Care help? Collaboration Ask to go with Good cop / bad cop Support, respect and validate oncologists feelings Early involvement Tip: nurses will often ask for help before MD Pain management- foot in the door Discuss automatic referrals with specific disease groups, i.e. pancreatic cancer Summary Questions or comments? 6