Main Points Definition of Palliative Care The Model of Concurrent - - PDF document

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Main Points Definition of Palliative Care The Model of Concurrent - - PDF document

Aug 15, 2022 136 likes •368 views

5/28/2013 Concurrent Care: the New Paradigm of Palliative & Oncologic Care Michael W. Rabow, MD Director, Symptom Management Service Helen Diller Family Comprehensive Cancer Center Professor of Clinical Medicine, UCSF May 23, 2013 Tom Reid,

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Concurrent Care: the New Paradigm

  • f Palliative & Oncologic Care

Michael W. Rabow, MD

Director, Symptom Management Service Helen Diller Family Comprehensive Cancer Center Professor of Clinical Medicine, UCSF May 23, 2013

Tom Reid, MD

Associate Director, Palliative Care Fellowship Assistant Professor of Medicine Division of Hospital Medicine, UCSF June 27, 2013

Main Points

 Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions

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Main Points

 Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions

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How knowledgeable are you about Palliative Care?

  • 1. Very knowledgeable
  • 2. Knowledgeable
  • 3. Somewhat knowledgeable
  • 4. Not at all knowledgeable
  • 5. Don’t know
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Once They Know About Palliative Care…

 Extremely positive about it and want access  >92% say:

 It is important  Patients with serious illness and their families

should be educated

 Likely to consider palliative care for a loved one

if they had a serious illness

 It is important that palliative care services be

made available at all hospitals for patients with serious illness and their families

Once They Know About Palliative Care…

 Universal

 Democrats and Republicans  Although don’t know about race and ethnic

differences in this definition

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What Palliative Care is Not necessarily

 about end-of-life & dying  hospice

Conceptual Shift for Palliative Care

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The Consumer Definition

  • Palliative care is specialized medical care for people

with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis.

  • The goal is to improve quality of life for both the

patient and the family. Palliative care is 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. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

Main Points

 Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions

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Mounting Evidence

  • Improved outcomes pre/post for cancer pts
  • Pain, Fatigue, Nausea, Depression, Anxiety, Drowsiness, Appetite,

Dyspnea, Insomnia, Constipation, and Satisfaction

Yennurajalingam, JPSM, 2011; Follwell, J Clin Onc, 2008 ; Kim, JPM, 2012

  • Positive impact of embedded PC in Oncology office
  • Improved ESAS by 21%
  • Referrer satisfaction of 9/10
  • 9720 minutes; 162 hours = time saved?

Muir, JPSM, 2010

  • Improved outcomes in a controlled trial
  • The CCT Trial at UCSF: outpatient palliative care team working with

primary care physicians

  • Dyspnea, Anxiety, Sleep, Spiritual Well‐being improved compared to

routine primary care

Rabow, Arch Intern Med, 2004

151 patients with NSCLC at Mass General

Immediate vs. delayed palliative care along with usual oncologic care

 Early pc patients with…

 Improved QOL  Less depression  Less chemo in last 2 weeks  Fewer hospitalizations in last month  Nearly 3 months longer survival (11.6 mos. vs. 8.9 mos., p<0.02)

Temel, NEJM, 2010

Prolonged Survival

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  • Mean cost savings of $2,282
  • Accounted for by…
  • Longer lengths of hospice stays
  • Higher hospice costs (mean of $1,125/patient)
  • Reduced costs
  • Inpatient visits (mean of $3,110/patient)
  • Chemotherapy (mean of $640/patient)

Greer J, McMahon P, Tramontano A, et al. J Clin Oncol. 2012;30 (suppl; abstr 6004)

Temel Study: The Finances Align The Post-Temel Universe

 Not either/or  Right from the start  Co-management  Coordinated, integrated

Concurrent Palliative & Oncologic Care

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5/28/2013 9 The American Society of Clinical Oncology now recommends concurrent palliative care for seriously ill cancer patients

“…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.” PC and Oncologists Focused on Different but Complimentary Tasks

  • Palliative Care:
  • Initial visits focused on sx mgmt, coping, rapport‐building, prognostic awareness
  • Later on resuscitation preferences and hospice
  • Oncologists:
  • Cancer treatment and management of medical complications
  • Co‐management allows each to focus on their area of expertise

Yoong, JAMA Intern Med, 2013

Sharing the Load: Co-Management

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Survey of Medical Oncologists

 Question texted to CA medical oncologists 8/2012: “If a patient with solid tumor has mets after chemo x3, would you refer to palliative care?”

Yes 22 23% No 13 13.5% It depends 61 63.5% Total responders: 96 100% It depends on … (most common) Type of tumor 21 Patient performance scale 30 Goals of care 7

Main Points

 Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions

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600 700 800 900 1000 1100 1200 1300 1400 1500 1600

# of U.S. Hospital Palliative Care Programs 2000‐2009*

(*AHA Annual Survey – 2010 data pending)

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Where is Palliative Care Available?

 Increasing:

24.5% (658) in 2000 to 63.0% (1568) in 2009

138.3% increase from 2000-2009 (CAPC 2011)  Large hospitals (300 or more beds) 85%

Mid-size hospitals (50-299 beds) 54%

Small hospitals (fewer than 50 beds) 22%  The Northeast 73%

The South 51%  Implications for socio-demographic, ethnic inequities  142 cancer centers (Hui et al. JAMA. 2010)

Outpatient PC in Cancer Centers

NCI site NCI site Non Non-NCI site I site Palliative care program 98% 78% Inpatient palliative care consult team 92% 56% Outpatient palliative care 59% 22%

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Availability of Expertise:

Certification in Palliative Care

 Physicians

ABMS approved PC as a sub-specialty (2006)

Grandfathering ended 2012

10 participating boards

5,000 physicians certified in HPM

 Nurses

National Board for Certification of Hospice & Palliative Care RNs

17,000 nurses, advanced, pediatric, nursing asst.

 Social Workers

Certified Hospice & Palliative Social Worker and Advanced Certified Hospice & Palliative Social Worker

 Chaplains

Palliative Care Chaplaincy Specialty Certificate (HealthCare Chaplaincy & The CSU Institute for Palliative Care)

But…

 1 cardiologist for every 71 heart attacks  1 oncologist for every 145 new patients with cancer  1 PC doc for every 300 deaths  1 PC doc for every 1300 patients with serious illness

= 6,000-18,000 projected gap in pc physicians

 Just for hospitals and hospices!

Lupu, J Pain Sx Mgmt, 2010

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How much Palliative Care to you provide in your daily practice?

  • 1. For all of my patient encounters
  • 2. For most of my patient encounters
  • 3. For about one‐half of my patient encounters
  • 4. For some of my patient encounters
  • 5. Rarely or never

Primary Palliative Care

All physicians must be competent in the basic skills of primary PC Generalist Palliative Care

  • Basic management of pain and symptoms

  • Basic management of depression and anxiety

  • Basic discussions about

Prognosis

Goals of treatment

Suffering

Code status

Quill & Abernethy, NEJM, 2013

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Secondary/Tertiary Palliative Care

Specialist Palliative Care

  • Management of refractory pain or other symptoms

  • Management of more complex depression, anxiety, grief, and

existential distress

  • Assistance with conflict resolution regarding goals or methods of

treatment

Within families

Between staff and families

Among treatment teams 

  • Assistance in addressing cases of near futility

Quill & Abernethy, NEJM, 2013

Workforce

 Need to think creatively…Who will do the work of PC?  UC San Marcos Palliative Care Institute  ELNEC  Mid‐career training  Special certification

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The Future: Improving Access

The window of opportunity for pall care is wide‐open: Accountable Care Organizations Patient‐Centered Medical Homes Bundled payments Adding palliative care (targeted to the highest cost, highest risk populations) to these new delivery and payment models and coordinating with primary care is key to success at improving quality and reducing cost.

Main Points

 Definition of Palliative Care  The Model of Concurrent Care  Role of the PCP in concurrent care  Pearls & Specific Interventions

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Clinical Pearls and Interventions: Primary Palliative Care in Oncology

 Pain: neuropathic pain  Fatigue  Depression

Neuropathic Pain – Diagnosis

No clear way to prevent chemo‐induced neuropathy

Diagnosis

Shooting, electrical, burning, tingling

Hypersensitivity

 Allodynia: Pain with non‐painful stimulus  Hyperalgesia: Over‐response to painful stimulus

Caveats

Recommendations largely extrapolated from studies of Diabetic Neuropathy and Post‐Herpetic Neuralgia

Most trials no longer than a few months

Treat the cause when possible

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Neuropathic Pain –Treatment

Opioids are first line

especially Methadone (mu agonist, NMDA antagonist)

Opioids better in combination with neurontin and at lower doses that either alone 

Gabapentin or pregabalin

Gabapentin: 100‐300 QHS; 100‐300 Q days to 3600mg

Pregabalin: 75mg BID; 150mg QWk to 600mg 

TCAs (nortriptyline, desipramine)

10‐25mg QHS; 25mg/wk to 100‐150mg 

SNRI

Duloxetine: 20‐30mg daily; 30mg increase after 1‐2 weeks

Venlafaxine: 37.5mg BID; 75mg/wk to 225mg (minimum)

Dworkin et al, Mayo Clin Proc, 2010

Neuropathic Pain –Treatment

Others with some evidence:

Lidocaine Patch

Capsaicin

TENS

Medical MJ: High CBD (cannabidiol) / Low THC strains (data from DM & HIV) 

Accommodation: OT, PT, orthopedic shoes

Safe to try:

Acupuncture

Exercise (blood flow)

No clear role for vitamin B, but probably doesn’t hurt to try 

Coming soon?

Light therapy: infrared, increase nitric oxide

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Fatigue – DDx

 Most prevalent, severe, and disabling symptom in advanced

cancer

Associated with cognitive changes  Look for and address other reversible causes

Depression, existential distress

Medication effects

Nutritional deficiencies (may not be correctable)

Endocrine abnormalities

Sleep disorders

Uncontrolled pain or other symptoms (vicious circle of fatigue‐sleep‐mood)

Fatigue –Treatment

Exercise (brief, repeated, aerobic, 20‐30 min total/day) (Cramp, Cochrane, 2010)

Energy conservation

Psycho‐social support (identity issues, education, self/family compassion)

Methylphenidate (or Modafinil 100‐200mg qAM)

2.5‐5mg PO BID

May increase by 5mg up to 20mg

Last dose no later than mid‐afternoon 

CAM: American Ginseng, hypnosis, acupuncture (limited data)

Steroids, megace, transfusions/erythropoetic stimulation

Mixed data and some risks 

Coming Eventually

Endocrinologic/anti‐inflammatory treatments for anorexia‐cachexia / fatigue

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Depression – Advanced Disease

 Many of the DSM criteria (particularly somatic symptoms) can

be the result of advanced disease

Anhedonia or physical incapacity?

Anorexia/Weight loss or cancer cachexia?

Insomnia, fatigue, poor concentration…  Key symptom: Hopelessness

Also social withdrawal, lack of reactivity, self‐pity

Depression – Advanced Disease

 Distinguish Anticipatory Grief

Variable mood

Normal self‐image

Hope and Pleasure

Absence of suicidality

Responds to support

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Depression –Treatment

Similarities with regular depression treatment

Screening is key

Relationship with clinician is important

Talk + Pharm = Better 

Differences from regular depression treatment

Potentially shortened timespan

More interactions with chemo & biologics (consider Lexapro/Celexa)

Consider analgesic, anti‐emetic, sedative s/e’s

Increased role for psychostimulants 

Coming Soon?

Ketamine po (case studies promising for depression and anxiety)

 “Palliative care services are available to

patients either on-site or by referral.” The Commission on Cancer Standard 2.4

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43

“Hope does not lie in a way

  • ut, but in a way through.”

Robert Frost