I have no financial disclosures.

Transcription

1 Palliative Medicine: Year(s) in Review I have no financial disclosures. Lynn A Flint, MD Staff Physician, SFVAMC Assistant Clinical Professor Division of Geriatrics Advances in Internal Medicine Objectives At the end of this session, learners will: 1. Have a working definition of palliative care 2. Understand the breadth of research going on in our field 3. Be familiar with recent developments in palliative care which are applicable to general practice What is palliative care? According to the World Health Organization: An approach that improves the quality of life of patients and their families facing the problems 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 3 accessed May 6,

2 What is palliative care? Matching treatments to patient goals Diane Meier, MD Palliative care consultation 1. Goals of care = prognosticate, assess goals, support hope, identify treatment plans 2. Symptom management 3. Some combination of the above 5 6 Three studies Relevant to general internal medicine Reviewed in ACP Journal Club, Journal Watch, or blogs Discussed in the news Case 1: 65-year-old woman with right knee pain. X-ray R knee radio-lucent area in the distal femur Chest x ray RLL mass Pathology non small cell lung cancer, EGFR mutation negative 7 8 2

3 Which therapy has been shown to prolong survival in similar patients? Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. N Engl J Med 2010;363: A. Platinum-based combination chemotherapy B. EGFR tyrosine kinase inhibitor C. Early evaluation and monthly follow-up by an outpatient palliative care team D. Radiation to the right distal femur E. A and C 20% 20% 20% 20% 20% 10 A. B. C. D. Countdown E. 9 Non-blinded, randomized, controlled study of ambulatory patients with newly diagnosed metastatic non-small-cell lung cancer Early palliative care along with standard oncologic care vs. standard oncologic care alone Eval within thee weeks, monthly visits with palliative care providers Primary outcome: change in QOL at 12 weeks 10 Palliative care visits focused on: Key Findings Illness understanding/education Intervention group: Symptom management higher QOL scores Pain Dyspnea Fatigue Nausea Depression Decision-making less depression more documentation of resuscitation preferences less aggressive care at the end of life lived two months longer Coping w life threatening illness

4 Quality of life Survival Depression Temel JS et al. N Engl J Med 2010;363: Temel JS et al. N Engl J Med 2010;363: Secondary studies ASCO Provisional Clinical Opinion: Depression and survival Depression predicted shorter survival Improvement in depression scores did not account entirely for prolonged survival in intervention group Less chemotherapy near death More understanding of prognosis over time patients with metastatic non small cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. J Clin Oncol 2012;30:310-5; J Clin Oncol 2012;30: ; J Clin Oncol 2011;29: J Clin Oncol 2012;30:

5 Can I apply these results to my patients? Outpatients from single site New diagnosis Mean age 65 Intervention not easily reproducible Clinical bottom line Palliative care concurrent with diseasedirected care resulted in improved quality of life and prolonged survival in patients with advanced lung cancer Offer palliative care to patients facing advanced cancer near the time of diagnosis Don t have an outpatient palliative care consultation service? Ask your local hospital or multispecialty group or cancer center Offer frequent follow-up to your patients with advanced cancer to address: Symptoms Understanding of illness Advance care planning Psychosocial needs Fast forward Despite several rounds of chemo, your patient develops shortness of breath and is found to have a large pleural effusion. Which of the following therapies has NOT been shown to significantly improve shortness of breath? A. Morphine sulfate 5 mg po Q 2 hours prn B. O2 via NC at 2L/min prn C. Medical air via NC at 2L/min prn D. Nebulized fentanyl E. Placement of a tunneled pleural catheter 16% 16% 25% 35% 7% 19 A. B. C. D. E. 20 5

6 Why is this important? Dyspnea is common in patients with lifelimiting illness Tends to worsen during the dying process Impact on quality of life, psychological wellbeing and social functioning Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnea: a double-blind, randomized controlled trial. Lancet 2010;376: patients with life-limiting illness, refractory dyspnea and PaO2>55 mmhg Randomized to O2 at 2L/min or air at 2L/min via concentrator Used gas for >15 hours/day x 7 days Primary outcome was breathlessness right now recorded in morning and evening Why study O2? O2 is frequently prescribed to patients with dyspnea who are near the end of life O2 has not been reliably shown to improve symptoms O2 has downsides Dry nares, epistaxis Stigma Another tube Expense Safety issues Key findings Groups did not differ in baseline characteristics Breathlessness improved in both groups Absolute change in breathlessness did not differ between groups Benefit within three days 18% did not want to receive O2 after the study

7 Can I apply the results to my patients? Outpatients from multiple sites Refractory dyspnea related to life-limiting illness Not hypoxic Not cognitively impaired No history of hypercarbia or hypercarbic respiratory failure with oxygen Hgb>10 Clinical bottom line More evidence that air movement near the nose/face improves the sense of dyspnea open the window get your patient a fan! Reassess of dyspnea within the first 72 hours of treatment with O2 If no benefit, discontinue O2 Some people don t want O2 What else can you offer? Dyspnea Review for the Palliative Care Professional: Treatment Goals and Therapeutic Options J Palliat Med 2012;15: Treatment of dyspnea Intervention Agent Conclusions Medical gas Pharmacologic Non-pharmacologic Surgical Oxygen-hypoxemic Oxygen-normoxemic Medical air-normoxemic Opiods-oral/IV Opiods-inhaled Inhaled furosemide Anxiolytics Fan Pulmonary rehab (select pts) Pleural catheter Bronchial stent (select pts) or Complementary Accupuncture -- or 27 Adapted from Kamal, et al. Journal of Palliative Medicine,

8 Clinical bottom line Ask patients with advanced illnesses about dyspnea Assess for contributing psychosocial, spiritual and emotional issues Opiods are effective in treating dyspnea More invasive interventions may be appropriate Case 2 Your 93 year old aunt Lives in nursing home Moderate dementia Wheelchair-bound, needs help with all ADLs CHF just hospitalized recently Since return to NH, spends nearly all her time in bed, talking little, refusing meals NH doc recommends hospice Your cousin calls you How can doctors know how long she ll live? Why is prognostication important? A. Instinct B. Actuarial tables C. Calculators based on large datasets D. Online tools E. We don t know how long she ll live F. All of the above 53% 23% 17% 0% 3% 3% A. B. C. D. E. F

9 Why is this important Doctors are not good at prognosticating The information helps providers and patients make decisions Older adults with multiple co-morbid conditions a very difficult group in which to prognosticate Illness trajectories Cancer Heart and lung failure Frailty and dementia Prognostic Indices for Older Adults: A Systematic Review JAMA 2012;307: Included studies of people 60 years and older, not disease-specific, and provided allcause mortality data Reviewed 16 unique indices Evaluated the quality of the indices considering potential bias, accuracy and generalizability Indices divided based on site of care Researchers did not recommend one index but made them more user-friendly 35 9

10 Can I apply the results to my patients? Older patients Not disease-specific Site of care specified Qualitative studies show most doctors use prognostic indices to confirm their gut feelings Clinical bottom line As our population ages, prognostication is going to be increasingly important in clinical decision-making Prognostic indices can be helpful to confirm our overall clinical hunch But these indices are not perfect and need to be studied more broadly Summary Palliative care is about matching treatments to patient goals Palliative care researchers are addressing a broad array of questions applicable to lots of providers and patients The work presented here supports early integration of palliative care careful consideration of the use of O2 further study to validate prognostic indices and determine their clinical utility Thanks for listening. Lynn Flint Lynn.flint@ucsf.edu