PALLIATIVE CARE FOR THE CANCER PATIENT Mountain States Cancer Conference November 2, 2013 Jean S. Kutner, MD, MSPH Gordon Meiklejohn Endowed Professor of Medicine OBJECTIVES To apply evidence regarding the benefits of palliative care to clinical situations. To identify palliative care needs among patients with cancer. PALLIATIVE CARE Should I recommend palliative care for my patient? When is the right time to engage palliative care? What are its benefits?
Quality Care in Advanced Illness: What Do Patients and Families Want? WHY IS PALLIATIVE CARE NECESSARY? Exponen'al rise in number and needs of frail elderly and their caregivers Cause of death shi:ed from acute sudden illness to chronic episodic disease Untreated physical symptoms Unmet pa'ent/family needs Inadequately trained health care professionals Unresponsive health care system facing enormous and increasing expenditures LIVING WITH CHRONIC ILLNESS Medical care for patients with advanced illness is often characterized by: inadequately treated physical distress fragmented care systems poor communication between doctors, patients, and families enormous strains on family caregiver and support systems. These concerns necessitate new models of care
WHAT IS PALLIATIVE CARE? Interdisciplinary health care specializing in the relief of suffering and the achievement of the best quality of life for patients with advanced illness, and for their families Specialized medical care for people with serious illnesses Focused on providing patients with relief from the symptoms, pain, and stress of a serious illness Goal: to improve quality of life for both the patient and the family Provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support Appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Center to Advance Palliative Care, 2011
Palliative Care aims to improve care in 3 domains: 1. Relieve physical and emotional suffering 2. Improve patient-physician communication and decision-making 3. Coordinate continuity of care across settings PALLIATIVE CARE = QUALITY CARE Research shows that palliative care: Relieves pain and distressing symptoms Clarifies goals of care and supports decision-making Improves quality of life Increases patient and family satisfaction with care Eases burden on providers and caregivers Helps patients complete life prolonging treatments Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; UC Davis Health System News; 2002; Carr et al, Vitas Healthcare, 1995; Franklin Health, 2001; Dartmouth atlas, 2000; Micklethwaite, 2002; Du Pen et al, J Clin Oncol, 1999; Finn et al, ASCO, 2002; Francke, Pat Educ Couns, 2000; Advisory Board, 2001; Portenoy, Seminars in Oncol, 1995; Ireland Cancer Center, 2002; Von Roenn et al, Ann Intern Med, 1993; Finn J et al ASCO abstract 2002
PALLIATIVE CARE INTEGRATES WITH CANCER CARE Managing symptoms that cause suffering Communication Exploring values and patient-centered goals Helping patients assess risk, benefit, burdens Creating care plans (and back-ups) to meet those goals WHO MIGHT CONSIDER PALLIATIVE CARE? Have a cancer and: Bothersome or difficult to control psychological or physical symptoms Desire for more information about what the future holds, wanting to make informed decisions Frequent hospitalizations or ER visits Progressive inability to care for self Caregiver distress Long hospitalization without evidence of progress In ICU setting with poor prognosis
COMMON REASONS FOR PALLIATIVE CARE CONSULTATION Clarification of patient and family care goals Pain and other symptom management Emotional, social, and spiritual support Coordination of care PALLIATIVE CARE: HOSPICE IS ONE COMPONENT Pain & Symptom Management Advance Directives Palliative Care Difficult Decisions Hospice Care Goals of Care Improve Communication HOSPICE VS. PALLIATIVE CARE Hospice focus is on pain and symptom management patient has a terminal diagnosis with life expectancy of less than six months not seeking curative treatment Hospice Palliative Care Palliative Care focus is on pain and symptom management patient does not have to be terminal may still be seeking aggressive treatment is not linked to reimbursement
PALLIATIVE CARE AS A SPECIALTY Medicine: American Board of Medical Specialities and American Osteopathic Association Board of Specialities formally recognized Hospice and Palliative Medicine as a new specialty in 2006 (www.aahpm.org) First board exam October 2008. First ACGME fellowship certification 2009 Nursing: National Board for Certification of Hospice and Palliative Nurses (www.nbchpn.org) Social work Advanced Certified Hospice and Palliative Social Worker (www.socialworkers.org) DEFINITIONS Primary palliative care: basic skills and competencies required of all health care professionals Secondary palliative care: specialists who provide consultation and specialty care Tertiary palliative care: care provided at tertiary medical centers where specialist knowledge for the most complex cases is research, taught and practices Systems-based approach: organized, deliberate approach to identification, assessment, and management of a complex clinical problem
EARLY PALLIATIVE CARE FOR PATIENTS WITH METASTATIC NON-SMALL- CELL LUNG CANCER Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. N Engl J Med 2010 363:733-42 METHODS Design: Non-blinded RCT of early outpatient palliative care integrated with standard oncologic care compared with standard oncologic care alone. All participants received standard oncologic care. Setting: Massachusetts General Hospital Inclusion Criteria: Pathologically confirmed metastatic NSCLC diagnosis within last 8 weeks, ECOG 0-2, able to read and respond in English Exclusion Criteria: If already receiving pall care not eligible, could receive after enrollment Funding: ASCO Career Development Award, Joanne Monahan Cancer Fund, Golf Fights Cancer KEY FINDINGS: QOL AND MOOD PC patients had 2.3 point increase in mean QOL compared to 2.3 decrease in QOL (p=. 04) PC group had lower rates of depression Standard Care Early PC p HADS-D 38% 16%.01 PHQ-9 17% 4%.04
KEY FINDINGS: END-OF-LIFE CARE 105 (70%) of patients died Standard care patients more likely to receive aggressive care (54% vs. 33%, p=.05) and less likely to have resuscitation preferences documented in EMR (28% vs. 53%, p=.05) PC patients had longer median survival (11.6 vs. 8.9 months, p=.02) KEY FINDINGS: SURVIVAL SUMMARY Early palliative care provided at the same time as life-sustaining treatments for patients with metastatic NSCLC has multiple benefits Palliative care is associated with improved mood, QOL, less use of aggressive therapies, and improved survival Results don t explain why
HOW DO I EFFECTIVELY AND EFFICIENTLY ASSESS PALLIATIVE CARE NEEDS? PRIMARY PALLIATIVE CARE ASSESSMENT COMPONENTS Understanding of illness, prognosis and treatment options Pain and symptoms Social and spiritual assessment Identification of patient-centered goals of care (if in a facility) Transition of care post-discharge CASE: MR K 75 year old man who moved to Colorado from the East Coast to be closer to family. Had been doing well until May - diagnosed with pancreatic cancer. Treated with chemotherapy, with terrible side effects, resulting in a hospitalization in the East. 1 st encounter within 1 week of discharge from hospital in the East and moving to Denver. First meeting with patient, wife, daughter, son-in-law and granddaughter. Primary concern: how he could feel better. On multiple medications, very fatigued and weak.
MR K: Assessed: Understanding of illness and treatment so far Symptoms Quality of life Sources of support (family and spiritual) Coping Goals His perspective Parallel goals: to feel better, gain back function, have a better quality of life; AND live as long as possible with the best quality of life possible Did not want to pursue further pancreatic cancer treatment if it would mean that he would feel as poorly as he current felt Approach: Referred to pancreatic cancer specialists to explore potential for additional treatments that would be better tolerated in the hopes that pancreatic cancer progression could be slowed Adjusted medications to address bothersome symptoms Connected with community-based palliative care Addressed advance directives Palliative care working collaboratively with oncology allowed patient to have the best quality of life for as long as possible.