Transcript Identify Triggers: Cancer

Beyond Advance Directives: The Oncologist’s Role in
Primary Palliative Care
David B. Brecher, M.D.,FAAFP
Adult Palliative Medicine Service
Tacoma General Hospital
MultiCare Health System
Washington State Medical Oncology Society Conference
Seattle, WA
Nov 16, 2012
Objectives

Understand the difference between Hospice and
Palliative Care

Discuss the expanding need for a Palliative Care
approach in oncology

Consider strategies to use when “giving bad news”

Techniques to discussing advance directives
Case: Introduction

72 Year old male “Mike”
 Pancreatic CA
11/2011
 Liver METS
04/2012

Widower

2 Sons

1 Daughter – patient lives with her

Has a faith affiliation

NO DPOA-H

NO AD – Full Code

Admitted: N/V, weight loss

Goals?
Weissman, D. (2005)
Hospice Care

Patients have a life expectancy of 6 months or less

Patient and family are the focus of care

Interdisciplinary team

Usually in the patient’s “home”
Palliative Medicine vs. Hospice
Palliative Medicine
Hospice
Patients Served
•At any stage of acute,
chronic, advanced or lifethreatening illness
•Prognosis of 6 months
or less
•Dying Patients of any
age
Services Provided
•Throughout duration of
chronic illness
•Patients can continue with
curative care
•Simultaneous with other
treatment
•Coordinated pain and
symptom control
•Care of spiritual needs
•Family support
•Assistance in making
decisions and transitions
between care and settings
•Coordination of care with
primary physician and other
specialists
•End of Life
•Curative treatment is no
longer an option
•Coordinated pain and
symptom control
•Care of spiritual needs
•Family support
•Assistance in making
decisions and transitions
between care settings
•Bereavement care for
survivors
Integration of Palliative Care into
Standard Oncology Care

Combined standard oncology care and palliative care early in the course
for any patient with metastatic cancer

Utilize palliative care and standard oncology care to optimize quality of
life, survival, and help to minimize costs
Oncology-Palliative Care Interface

Increasing recognition that Palliative Care = Excellent
Oncology Care (US News Best Hospitals Criteria)

Emphasis on patient values and goals (Kaldjian 2008)

Patients prefer to focus on values and goals, rather than
procedures (Hawkins 2005)
What is Palliative Medicine?
Palliative Medicine provides symptom management to patients
with debilitating acute or chronic disease, and/or life threatening
illness
Palliative Medicine focuses on providing relief of physical,
psychosocial, and spiritual pain (relief of “total pain”)
(Cicely Saunders, MD)
There is never “nothing else that can be done…”
Value of Palliative Care

Improves quality of life

Reduces major depression

Less aggressive EOL care

Patients live longer, and with better outcomes
(11.6 months vs 8.9 months, p < 0.02)
(Temel 2010)
“Palliative Care is about matching
treatment to patient goals”
Diane Meier, MD
Shared Medical Decision Making

Patient/Surrogate

Medical Team (“all on the same page”)

The Medical Team can (has an obligation to) make a recommendation
as to what medical care is most likely to achieve the patient’s goals, and
therefore what is appropriate
Tools

Time limited trial with defined goals

“Hope for the best, and meanwhile
prepare for the worst…”
End-of-Life Experiences
for Cancer Patients
End-of-Life Conversations
“It’s too early until it’s too late.”
End-of-life discussions
are a high-value
clinical intervention
Identify Triggers: Cancer

Prognosis-related triggers
Stage 4 Disease
PPS < 40%/ECOG > or = 3

Disease-based/condition-based criteria, e.g.:
All patients with NSCLC, pancreatic cancer, GBM
Patients over 70 with AML

Treatment-based identification
Failed second line therapy
Enrolled in a clinical trial
(NCCN 2011 Guidelines)
The end-of-life experience of
cancer patients
Patients who receive hospice care report better quality of life
Aggressive care is associated with reduced quality of life, physical and
emotional distress
% of Cancer
Patients
Receiving
Chemotherapy
during Last
Two Weeks of
Life
% of Cancer
Patients
Hospitalized
during Last
Month of Life
% of Cancer
Patients
Admitted to
ICU during
Last Month of
Life
% of Cancer
Patients
Enrolled in
Hospice by
Last Month of
Life
% of Cancer
Patients Dying
in Hospital
Washington
6.4
58.4
21.1
49.4
26.9
Tacoma (All
8.3
56.0
26.4
55.1
28.5
6.0
61.3
23.7
54.6
28.8
Hospitals Referral
Region)
National
AVG
(Dartmouth Atlas – 2003 to 2007 data)
Cancer Patients and EOL Discussions

Only 37% of cancer patients with average survival of 4
months reported having had discussion about EOL issues
with physician (Wright 2008)

Although 95% of hospitalized oncology patients believe it is
important to have discussions about advance directives/EOL
care, only 41% have them

Major barrier: Oncologists don’t bring up issue (Dow 2010)
Improving Quality

Early discussion of end-of-life care issues among
cancer patients is associated with improved
outcomes:

Patients more likely to have wishes followed

Increases quality of life

Reduces rate of hospitalization and ICU admission

Increases use of hospice

Reduces stress, anxiety, depression, PTSD and
bereavement morbidity in survivors

Improves family satisfaction
(Wright 2008)
Delivering “Bad News”
Six Steps
1
Getting Started
2
Finding out how much the patient knows
3
Finding out how much the patient wants to know
4
Sharing the information
5
Responding to the patient’s/family’s feelings ––
Don’t say “I know how you feel”
6
Planning and follow-through
Discussing
Advanced Directives
Learning Objectives

Know why it is important to discuss Advance Directives status with
patients/families

Know how to discuss Advance Directives status – Make a
Recommendation

Know how to document Advance Directives status
The Surprise Question

Would you be surprised if this person died in the next 6-12
months?

(Then let’s make sure the patient, family, caregiver,
guardian…is not surprised either)
Advance Directives

Code status preference – just part of it

Durable Power of Attorney for Health Care Decisions – (DPOA-H)

Living Will
* Withhold or Withdraw life-sustaining treatment
* Artificial Nutrition & Hydration

Physician Orders for Life Sustaining Treatment – (POLST)
Surrogate Decision Maker

DPOA-H

Decision Making Capacity
- Not “competency”

Substituted judgment
- If the patient was able to speak for themselves today, how would they
answer these questions?
DNAR: Who Initiates?

Oncologists are in the ideal position to initiate DNR discussions

Patients typically rely on their oncologists to initiate the discussion, as
they often serve as patient’s PCP

Patients/families often think a lot about dying – they are often awaiting
permission to talk about it – “the elephant in the room”
Acknowledge the Elephant in the Room

“This is a life-threatening
Illness”

“You are at high risk for dying
from this malignancy”
DNAR: How –
Establish patient goals/expectations
Treatment Goals:

“Given the severity of your illness, what is most important to you right
now?”

“How do you think about balancing quality of life with length of life in
terms of your treatment?”

“What are your biggest fears/concerns?”

“What are your hopes for the future?”
DNAR Discussion

Often a facilitated family discussion

“How much do you want to know?”

Get the patient/family talking – use open-ended questions
(i.e. “Ask – Tell – Ask”)

Talk less, listen more
HOW – Statements to Avoid

“Do you want us to do everything” – Implies that without CPR we will
“do nothing”

“There’s nothing else that can be done”
There is always a lot that can be done to provide
physical, emotional, and spiritual support
Barriers

We avoid the concept of Death

Physicians are often overly optimistic about prognosis

Unrealistic belief in technologic solutions

Loss of hope for the future

If no CPR – “nothing will be done”

It takes too much TIME to talk about…
Key Points in Discussing
Advance Directives

Explore the patient’s understanding of
their illness

Explore the patient’s values and
expectations

Continue to provide good medical care
to support physical, emotional and
spiritual needs

Address other related issues
(Eventually)

Understand the likely outcome of CPR

Make a recommendation consistent
with the patient’s goals
-POLST

Check for patient/family
understanding
-Living Will i.e. role of
Artificial fluid/nutrition

Do not force a decision – be sure to
follow-up/try to establish a
relationship
-Five Wishes
-DPOA-H
-Hard Choices
Case: Conclusion
Goals:
 To
go to his daughter’s home
 Remain
independent
 Make
a recommendation?
Palliative Medicine Resources

Center to Advance Palliative Care www.capc.org

National Hospice and Palliative Care Org
www.nhpco.org

American Academy of Hospice and Palliative
Medicine www.aahpm.org

Hard Choices for Loving People, Dunn, H, A & A
Publishing, Inc, 5th Ed. 2009

EPERC (End of Life/Palliative Education Resource
Center, www.eperc.mcw.edu
References

Back AL, Arnold, RM, MD; Quill TE, Hope for the Best, and Prepare for the Worst, Ann Intern Med. 4 March 2003;138(5):439-443

Block, S, Moving Conversations about the End of Life Upstream: A Systems Approach, University of Washington, October 2012

Dartmouth Atlas, The Dartmouth Institute For Health Policy & Clinical Practice, http://www.dartmouthatlas.org

Dow LA, Matsuyama RK, Ramakrishnan V, et al. (2010) Paradoxes in advance care planning: The complex relationship of oncology patients, their physicians, and advance
medical directives. J Clin Oncol 28:299–304

Ferris F, Bruera E, Cherny N, Cummings C, Currow D, Dudgeon D, et al. (2009) Palliative Cancer Care a Decade Later: Accomplishments, the Need, Next Steps—From
the American Society of Clinical Oncology, JCO, vol. 27 no. 18 3052-305

Kaldjian LC, Curtis AE, Shinkunas L, Cannon KT. Goals of care toward the end of life: a structured literature review. American Journal of Hospice and Palliative
Medicine 2009;25:501-511.

National Comprehensive Cancer Network Guidelines, “Palliative Care” Version 2.2011, NCCN.org

Smith T, Temin S, Alesi E, Abernethy A, Balboni, T, Basch, E, et al. (2012) American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of
Palliative Care Into Standard Oncology Care JCO vol. 30 no. 8

Temel JS, Greer JA, Muzikansky A, et al. (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733–742.

Weissman, D, Palliative Care Improving Quality and Reducing Cost, 2008, Center to Advance Palliative Care, www.capc.org

Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL, Jackson VA, Block SD, Maciejewski PK, Prigerson HG, et al. Associations between endof-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008 Oct 8;300(14):1665-73.
Questions?
Thank you!