3/7/2017 17 th Multidisciplinary Management of Cancers: A Case based - PDF document

3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Overview Case 1: California’s End of Life Options Act End of Life Care 2017 Case 2: Nutrition at the end of life SESSION CHAIR: Case 3: Prognosis in the era of immunotherapy Kavitha Ramchandran, MD Case 4: Early integration of palliative care into oncology care Thoracic Oncology and Palliative Medicine Summary of Key points Stanford Hospital and Clinics References 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Panel Members: Overview Scott Christensen MD, Medical Oncology, UC Davis John Hausdorff MD, Medical Oncology, Pacific Cancer Care Case 1: California’s End of Life Options Act David Magnus PhD, Center for Biomedical Ethics, Stanford Daniel Mirda MD, Medical Oncology, Annadel Medical Group Case 2: Nutrition at the end of life Mike Rabow MD, Palliative Care, UCSF Piyush Srivastava MD, Medical Oncology, TPMG Case 3: Prognosis in the era of immunotherapy Assistant to session chair: Case 4: Early integration of palliative care into oncology care Diane Tseng MD PhD, Oncology Fellow, Stanford Summary of Key points References 1

3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1: California’s End of Life Options Act EOLA California Requirements: Mrs. Mobitz is 75 years old and was diagnosed one month ago with squamous cell • Attending physician and consulting physician have diagnosed the patient with terminal carcinoma of the lung. She is not interested in chemotherapy or immunotherapy, and illness with six month or less life expectancy would like the option of ending her life on her terms. She seems to interact normally with • Patient has voluntarily expressed a desire to receive aid ‐ in ‐ dying medication you, and does not appear to be clinically depressed – rather, she is resigned. • Patient has the mental capacity to make and communicate healthcare decisions • Patient is a resident of California • Patient is at least 18 years old • Patient has the physical ability to self ‐ administer and swallow the aid ‐ in ‐ dying medication • Applicable documentation must be completed by patient’s attending and consulting physician 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1: California’s End of Life Options Act Case 1: California’s End of Life Options Act Mrs. Mobitz is 75 years old and was diagnosed one month ago with squamous cell carcinoma of the lung. 1.2) You say, “ What makes you ask for something like this?” She answers that she does not want to die in terrible pain. How might you respond? 1.1) Her husband asks: “Is she eligible for the pill?” a. Yes, because she has less than six months, meeting the “definition” of terminal illness. a. Most cancer patients don’t die in terrible pain. b. Yes, if she continues to show evidence of having “capacity”. b. We have lots of good pain medications c. Yes, if there is no good evidence of depression or anxiety interfering with her judgment. c. Getting on to hospice care opens the door to having the focus of care be pain and If present, this require evaluation by a psychiatrist or clinical psychologist. symptom management, and that hospice nurses are experts in this. d. Yes, if she asks now, and again at least 15 days from today, and signs the “Attestation” d. Point out that for patients with intractable pain, “palliative sedation” brings state of form (thereby providing a written request). unconsciousness, so they don’t feel any pain. e. All of the above e. All of the above. f. Not of the above 2

3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Initial Steps, EOLA Road Map: Requirements for the Consulting Physician Explore Patient Fears: Establish Plan: Respond to Emotions: Encourage Discussion: Patient Understanding: In addition to the attending physician, a consulting physician who is independent from the Encourage Discussion Not all ELOA requests are about proceeding What does the patient understand about What about death is most concerning? Allow for silence (it is your best friend) Recognize PAD inquiries as really inquiries • • • • • Monitor use of touch about death and dying What are you hoping for? What goals do attending physician needs to evaluate the patient. with physician aid in dying his/her/their illness and prognosis? • • Pause and transition discussion Elicit with open ‐ ended questions Most requests are about discussing fears you have? In the time ahead, what is most • The consulting physician needs to: • • Explore Patient Fears “Tell me more…” important to you? and worries about death and dying Provide missing information • • A.Examine the individual and his or her relevant medical records. Acknowledge patient openness Clarify the individual plan to meet the goals Listen and respond Avoid medical jargon • • • • B.Confirm in writing the attending physician’s diagnosis and prognosis. Most patients with advanced illness will Family members may be on different page of patient • • Elicit Understanding Focus on items that you will be offering to have already thought about dying at some and have different goals • C.Determine that the individual has the capacity to make medical decisions, is acting point patient versus what you will not voluntarily, and has made an informed decision. Emphasize ongoing care regardless of • Respond to Emotions D.If there are indications of a mental disorder, refer the individual for a mental health personal views specialist assessment. E.Fulfill the record documentation required under this part. Establish Plan F.Submit the compliance form to the attending physician. Adapted from Palliative Care Network of Wisconsin. Palliative Fast Facts 23 Discussing DNR Orders. Von Gunten and Weissman May 2015. 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1: California’s End of Life Options Act Case 1: California’s End of Life Options Act 1.3) A few weeks later, she says she still wants to pursue having the “pills,” because she Question for the panel— wants to maintain as much control as possible. She seems to have capacity, has no apparent psychiatric condition, and you have her sign the “Attestation” form and you What have been your personal experiences at your respective institutions with California’s work through the MD “Checklist” form with her. What’s the next step? End of Life Options Act? a. Give her the pills. b. There needs to be a second opinion from another MD. c. Refer to psychiatry because psychiatric evaluation is mandatory. d. You’ve decided you cannot participate – “Above all, do no harm” e. You don’t feel comfortable. The law does NOT mandate that you refer to a physician who is willing to participate. 3

3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Overview Case 2: Nutrition at the end of life Case 1: California’s End of Life Options Act 2.1) A family meeting is held and the decision made to pursue hospice care. He has been on TPN during this admission. Should TPN be continued? Case 2: Nutrition at the end of life A) Artificial nutrition is not consistent with the philosophy of hospice and should be Case 3: Prognosis in the era of immunotherapy stopped B) TPN should be continued for now, but if the patient appears uncomfortable, then it Case 4: Early integration of palliative care into oncology care should be withdrawn C) TPN should be continued until he has taken care of his business affairs Summary of Key points D) The benefits and risks of TPN should be discussed with the patient and the decision of whether or not to continue TPN should be a shared decision References 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 2: Nutrition at the end of life Case 2: Nutrition at the end of life Mr. Jones is an 82 year old gentleman with pT3b N0 M0 high grade invasive papillary Design: urothelial carcinoma, who underwent a radical cystectomy with ileal conduit. He • Review of 17 prospective, randomized controlled trials testing whether parenteral experienced his first recurrence one year later, for which he was treated with carboplatin nutrition would be clinically beneficial for cancer patients receiving either chemotherapy and gemcitabine. He is admitted to the hospital with nausea and vomiting and found to or radiation therapy have a malignant bowel obstruction. Results/Conclusions: No significant evidence that parenteral nutrition has a consistent positive effect • • Most studies have small numbers of patients, so small benefits can be missed Koretz et al. J Clin Oncol 1984;2(5):534 ‐ 8 4