8/7/2018 Disclosures Palliative Care Pearls: What Works, What Doesn’t I have no financial disclosures to report. BROOK CALTON, MD, MHS ASSISTANT PROFESSOR OF CLINICAL MEDICINE DIVISION OF PALLIATIVE MEDICINE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Docusate for Constipation What Doesn’t Work… Study: Double-blind 1. Docusate RCT 2. Chemotherapy Near End of Life 74 patients, 3 inpatient Canadian 3. Oxygen in Non-Hypoxic Patients with Dyspnea hospices Randomized to 10 days of: Senna 1-3 tabs/day + docusate 100 mg BID Senna 1-3 tabs/day + placebo BID Tarumi Y. J Pain Symptom Manage. 2013;45(1):2-13 1
8/7/2018 Study Results Docusate group had marginally larger volume of stool p=0.06; stool consistency was slightly different between groups No difference in: Average # of bowel movements/day Patients’ perceptions of the difficulty or completeness of defecation Pain Percent of patients requiring additional bowel intervention (74% placebo; 69% docusate)] Additional issues: tastes horrible, pill burden Chemotherapy Near End of Life Docusate for Constipation (continued) Goals of chemotherapy No appreciable benefit of adding for patients with Docusate to Senna in hospice patients metastatic cancer: Live longer 1. What works for constipation: Live better 2. Always rx laxative with opioid Study: Association of Start with Senna, then add Miralax, Lactulose, etc chemo in last 6 months of life with caregiver- Suppository or enema (avoid Fleets) if > 3-4 days reported quality of life in Hydration and activity last week of life and Consider Methylnatrexone for opioid-induced survival constipation if above not working Prigerson HG. Jama Oncol 2015; 1(6):778-784 2
8/7/2018 Chemotherapy Near End of Life Study Results No improvement in QOL 661 patients with advanced met cancer who had for patients with moderate or poor baseline functional progressed on prior therapy status MD estimate of < 6 months to live Chemo associated with ½ of patients were on chemo at enrollment worse QoL for patients with better functional Median survival 4 months status at baseline Patients with good functional status were more likely No difference in survival to receive chemo (though study not designed for this) Think twice about whether to support palliative chemotherapy for patients with metastatic cancer who are near the end of life. Supplemental Oxygen for Supplemental Oxygen Trial Dyspnea In Non-Hypoxic Patients Study: Palliative oxygen therapy widely used for Double-blind RCT dyspnea 239 outpatients in US, Australia and UK with life- limiting illness, refractory dyspnea, and Potential benefits: placebo effect, family PaO2>55mHg feels like “doing something” Randomized to RA or O2 at 2 LPM x 7 days Potential burdens: ties patient down, social Instructed to use O2 at least 15 hours/day stigma, uncomfortable, nosebleeds, fire risk Abernathy A. Lancet 2010;376(9743):784-93 3
8/7/2018 What Works for Dyspnea Study Results No difference between supp O2 vs RA by NC in: Treat the underlying cause Pleural effusion, PE, pna, ascites Mean AM Breathlessness scores Opioids Mean PM Breathlessness scores Low dose, Safe even in COPD Quality of Life Position Breathing training Fan and/or fresh air Compared with RA NC, oxygen by NC Cold cloth to face provides no benefit for dyspnea in Acupuncture in COPD patients who are not hypoxemic. Ekstrom M. Ann Am Thoracic Soc 2015; 12(7):1079-92 Bausewein C. Cochrane Database Syst Rev. 2008(2):CD005623 Audience Poll What Works! How knowledgeable are you about Palliative Palliative Care 1. Care? 48% Skillful and Sensitive Communication 2. A. Not at all knowledgeable Advance Care Planning 3. B. Somewhat knowledgeable 25% C. Knowledgeable 12% 11% D. Very knowledgeable 3% E. Don’t know e e w e e l l l l b b o b b a a a a n e e e e k g g g g t d d ’ d d n e e e e o l l w l l w w w D o o o o n n n n k K k k l t y l a r a e h t V w a e t o m N o S 4
8/7/2018 Public Misunderstanding Once they know… Once they know… 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 Palliative Care Core Elements Symptom management • Specialized medical care by a team of doctors, Excellent communication nurses, social workers, chaplains and other Comprehensive care specialists for people with serious illnesses. • Focuses on providing patients with relief from Bio-psycho-social-spiritual the symptoms, pain, and stress of a serious Family illness—whatever the diagnosis. Continuity • The goal is to improve quality of life for both the Team-based care patient and the family. http://www.capc.org/building-a-hospital-based-palliative-care- program/case/definingpc 5
8/7/2018 Palliative Care is Not… A New Paradigm For older adults only End of Life Care Old Medicare Life Prolonging Care Hospice Hospice Care Benefit Palliative Care End of Life Care Life Prolonging New Hospice Care Care Palliative Care Hospice Palliative Care Improves Value Early Palliative Care Intervention Study: Quality Improves Costs Reduce Non-blinded, RCT (single Reduction in symptom • Lower hospital site) burden cost/day Improved quality of life Ambulatory patients with • Less use of ER, Longer length of life newly diagnosed met NSCLC hospital, ICU Increased family Immediate PC + onc vs onc satisfaction • Reduction in 30d Primary outcome: change in Better family readmissions QOL at 12 weeks bereavement outcomes • Labs, imaging, Care matched to patient pharmaceuticals centered goals Temel J. N Engl J Med 2010;363:733-42 6
8/7/2018 When Should I Consult Palliative Care? Study Results Baseline characteristics did not A. At time of diagnosis of a serious illness differ between groups B. At time of change of illness Intervention group: 86% Better QOL scores C. At time of illness crisis Less depression D. When cued by patient or family More documentation of resuscitation preferences E. Any of the above Less aggressive care at the end 10% 3% 1% of life 0% Lived two months longer s s e . s i . v . s . . e i o . o n r a c b l l t a f i s n o s e e f e s o i h i n t t s e l a o g l p f i o n n f g o y a b y a h n i e d d c m A e f f u o o t i c e t Palliative Care appears beneficial for patients e A n m m e i h t i t t W t A A with newly diagnosed metastatic NSCLC. How to Get It What to Say Palliative Care is: “Specialized medical care for people with serious illness” “An extra layer of support” www.getpalliativecare.org “A team that focuses on quality of life and works with me to help you feel as good as you can for as long as possible” CAPC 2015: America’s Care of Serious Illness 7
8/7/2018 Yet, patients and families report… Skillful and Sensitive Communication Not enough: Patients and families want their providers to: Contact with physician 78% Bring up end of life issues Emotional support (pt): 51% Be available and willing to talk AND listen Info re: dying process: 50% Provide timely and clear information Emotional support (family): 38% Encourage questions Help with pain/dyspnea: 19% Patients tend to want: Prognostic information And a lack of: For bad news to be delivered sensitively Coordination Control over the timing of conversation Access Active participation in decision-making, but desire Anticipatory Guidance recommendations Assurance Butow Support Care Cancer 2002 Gold Intern Med J 2009 Steinhauser J Pain and SxMgmt 2001 Teno et al. JAMA 2004;291:88-93 . Wenrich Arch Int Med 2001 In general… Audience Poll For me, the biggest barrier in having conversations about We spend a lot of time talking serious illness/end-of-life with my patients is: But sometimes, not enough A. Knowledge (of how to have the 64% conversation) We interrupt a lot B. Time We miss emotional cues C. Money (I can’t or don’t know how to bill) We lack education and 13% 13% D. Personal Discomfort - Fear of Taking 9% confidence 1% Away Hope or Damaging the Relationship e ! m . y . . . . s . . i . k . a T o a e e h T Tulsky Ann Int Med 1998 h s t w f i e o o f f v n r u a k a t Anderson JGIM 2011 h e s E. None, this stuff is easy! t ’ F s o n i t o - h t t w d o r , Marvel JAMA 1999 o r e o f n h m o f t o o ’ N ( n c Levinson JAMA 2000 a s e c D i g d ( I l e y a l n Ury Acad Med 2005 w e o n o o r s n M e K P 8
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