Function 4/20/2018 Complex Illness Support Alongside Standard Oncology Care for Patients with Incurable Cancer Kim Bland, DNP, APRN-NP, FNP, AOCN Objectives Discuss Complex Illness Support Review rationale for early Palliative Care Summarize Outpatient Experience Determine lessons learned Trajectories of Function and Well-Being over Time in Eventually Fatal Chronic Illnesses High Disease Trajectory Initial Therapy (curative) Cancer Disease-free Relapse Progression Increasing Symptoms Organ System Failure Salvage Therapy Progression-free Palliative Care Deterioration Low Dementia- Frailty Death Comfort Care (Hospice) Time Death Outpatient Consultation Service Justification: most patients spend most of their time outside of hospitals Opportunity Improved quality patient care Potentially decreased acute care stays and mortality Increased efficiency in health care systems and accountable care organizations 150 patients with newly diagnosed metastatic NSCLC Background Early, Integrated Palliative Care in Patients with Metastatic Lung Cancer Temel et al., NEJM (2010), 363 Early palliative care integrated with standard oncology care Standard oncology care Palliative Care Model Palliative care provided by physicians and nurse practitioners Visits occurred in the Cancer Center (medical oncology, radiation oncology or chemotherapy visits). Oncology and palliative care visits were done in tandem or simultaneously. Visits were not scripted or prescribed. If patients were admitted to the hospital, they were followed by the palliative care team 1
Results Newly diagnosed metastatic NSCLC patients enrolled between 2006-2009 Reported better QOL and less depression Chose less aggressive care at EOL Survival prolonged by 2 months (11.6 versus 8.9 months) Clinically meaningful improvements in quality of life and mood Literature Review: Early Palliative Care Incorporation of palliative care ALONGSIDE standard oncological care for NSCLC patients - Longer Median survival - Increased Quality of life - Improved accuracy of illness perception - Less aggressive treatments at end of life - Fewer depressive symptoms Temel et al., NEJM (2010), 363. Early Palliative Care Intervention Project Summary: More accurate perception of prognosis ( incurable ) October 31, 2016 through March 16, 2017 Less likely to receive aggressive treatments near the end of life 13 referring physicians: 1 PCP and 12 Oncologists Referral Guidelines Incurable cancer Significant symptom burden related to cancer or treatment Poor performance status (PPS 50 or less) Psychosocial situation interfering with receipt of treatment Multiple admissions / ER visits Help with complex decision making / advance care planning / goals Conflicting goals between patient and family Existential distress may benefit from support Patient or family request support and consultation Seen by inpatient palliative care and needing follow up Concerns about caregivers / support systems Assistance with complex illness management Discussion and referral for hospice care How Should we Design Interventions to Improve The Delivery of Cancer Care? 1. Focus on patients in the ambulatory care setting 2. Allow patients to have cancer care and Palliative Care 3. Provide early and continued relief from physical and psychological symptoms 4. Enhance communication between patients and clinicians AND patients and their families to improve decision-making 5. Provide the most appropriate care at end of life 2
Embedded Clinic Model ACCESS Collaborative relationship between a host clinic and palliative care staff All costs of the clinic operations are born by the host clinic Patients referred predominately from the host clinic Defined clinical pathways or protocols may exist defining patient flow between the host and palliative care staff Complex Illness Support Realistic patient and family-centered care goals: Re-evaluate throughout the duration of illness Empower patients and families about healthcare choices Facilitate referrals to appropriate community programs Encourage Advanced care planning Expert symptom and comfort management: Whether pursuing aggressive life prolonging care or comfort measures only Independent of prognosis Focus on patients with progressive life limiting illness with prognosis of one year or less Actual Referral Diagnosis Metastatic Breast Metastatic Pancreatic Stage I NSCLC (Poor PS) Metastatic pleural Mesothelioma Metastatic pelvic adenocarcinoma, unknown primary Myelodysplastic syndrome Synchronous Stage Lung cancer and metastatic melanoma Metastatic lung cancer Stage Ib Lung cancer, new epiglottic mass probably cancer Stage IIIA lung cancer; difficult surgery decision Stage IV endometrial cancer Stage IIIB cervical cancer Dementia, prostate cancer Acute Myelogenous Leukemia, history of Breast and Colon Cancer Number of patients seen: 18 Number of patient visits: 22 (13 new and 9 follow up) Race: 16 Caucasian / 2 Hispanic Gender: 2 Male / 16 female Average age: 71.7 years old Treatment status: Receiving cancer treatment: 14 Stopped or refused treatment: 3 Had not yet started treatment: 1 Enrolled to hospice: # 10 One remained alive One patient refused hospice, expired Mortality: 10 of 18 expired: 56% **Indicates patient expired 3
Emergency department use and disposition: 2 patients Weakness and pain discharged home Cough, hallucinations, vomiting: was on hospice, returned to hospice Hospitalizations and length of stay: 8 patients Cholecystectomy outpatient surgery: 1 day Syncope observation patient : 3 days Pulmonary Emboli: 3 days Fatigue, nausea: 9 days New atrial fibrillation, Cardizem drip: 3 days Malignant pleural effusion, tapped: 10 days Weakness: 11 days; discharged to Skilled nursing facility Anemia, dyspnea: 10 days; discharged to home hospice Sepsis: 13 days; discharged to hospice house ICU use: 1 patient Sepsis, intubated. Patient had been seen inpatient and outpatient prior, very resistant to discussions on code status, advance directives, and goals of care. Treatment at end-of-life Average Number of Days from last chemo : 43.6 days Average Number of Days from last chemo or Radiation: 47.16 days Average Hospice days: 20.2 days One patient refused hospice = no hospice days Patient satisfaction with Complex Illness Support All surveyed strongly agreed: The CIS team was respectful and professional I was able to talk about my goals and preferences for future care The team helped me to feel more comfortable (Emotionally and with symptom management) The CIS team helped to coordinate my care I am satisfied with the CIS team Comparison to benchmarks CIS Literature Chemo last 14 days 6% 5.6-20% Chemo last 30 days 12% 9-50% ED visit 11% 4.57-47.8% Hospitalization 44% 4-92% ICU use 6% 5.86-15.4% Hospice admission 94% 47-59.9% Hospice days 20.2 4-19.7 Acute care death 0 28.6% 4
Reflections No show patients are reflective of misperceptions about palliative care, how complexly ill patients are, and late referrals. Patients and providers are accepting of and asking for outpatient Complex Illness Support In this five month project, 56% of patients referred to Complex Illness support died. This affirms the rationale and need for early supportive care intervention. Expanding services would enhance patient care and satisfaction, as well as provide benefit to patients, families, and the healthcare system. References: Temel, J., Greer, J., Muzikansky, A., Gallagher, E., Admane, S., Jackson, V.,... & Lynch, T. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. The New England Journal of Medicine, 363(8); 733-742. Stuver, S., McNiff, K., Fraile, B., Odejide, O., Abel, G., Dodek, A., & Jacobson, J. (2016). Novel data sharing between a comprehensive cancer center and a private payer to better understand care at the End of Life. Journal of Pain and Symptom Management, 52(2); 161-169. Von Roenn, J. & Temel, J. (2011). The integration of palliative care and oncology: The evidence. Oncology, 25(13); 1258-1266. Greer, J., Pirl, W., Jackson, V., Muzikansky, A., Lennes, I., Heist, R., Gallagher, E., & Temel, J. (2012). Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. Journal of Clinical Oncology, 30(4); 394-400. Abramowski, M. & Astarita, P. (2017). Building a palliative care program from the inside out. Oncology Issues, Jan-Febr; 37-46. Murillo, J. & Koeller, J. (2006). Chemotherapy given near the end of life by community oncologists for advanced non-small cell lung cancer. The Oncologist, 11; 1095-1099. Nappa, U., Lindqvist, O., Rasmussen, B., & Axelsson, B. (2011). Palliative chemotherapy during the last month of life. Annals of Oncology, 22; 2375-2380. Loh, K., Kansagra, A., Shieh, M., Pekow, P., Lindenauer, P., Stefan, M., & Lagu, T. (2017). Predictors of the use of specific critical care therapies in patients with metastatic cancer. JNCCN, 15(1); 22-30. Magarotto, R., Lunardi, G., Coati, F., Cassandrini, P., Picece, V., Ferrighi, S., Oliosi, L., & Venturini, M. (2011). Reduced use of chemotherapy at the end of life in an integrated-care model of oncology and palliative care. Tumor., 97: 573-577, 5