Jeff Myers MD, CCFP, MSEd Head – Palliative Care Consult Team

transcript

Carmelita Lawlor Lecture: HPCO Conference, April 28, 2012

Our Time Has Come:Lessons Learned From The Cancer Experience

Jeff Myers MD, CCFP, MSEdHead – Palliative Care Consult TeamCo-Program Head – Patient and Family Support ProgramOdette Cancer Centre, Sunnybrook Health Sciences CentreW. Gifford-Jones Professor in Pain and Palliative CareHead and Associate Professor – Division of Palliative Care, Department of Family and Community MedicineFaculty of Medicine, University of Toronto

What do I believe to be the mainlesson for Palliative Care with experience

in the oncology setting thus far?

“Early Palliative Care” might NOT be the best approach.

Dr. Jeff Myers April 28,

PC and Oncology

How might the relationship impact the current PC momentum?

How must we be strategic in our thinking as we plan for the future role of the field?

Dr. Jeff Myers

April 28, 2012

Early Palliative Care - NEJM

Pts assigned to “Early Palliative Care”:\ • Significantly better quality of life • Fewer depressive symptoms • Less likely to receive aggressive EOL care• Significantly longer median survival

Median SurvivalStandard care group = 8.9 months Palliative care group = 11.6 months (p=0.02)

(despite receiving “less aggressive EOL care”)

•Important: the study population (n=151) was comprised solely of pts with incurable metastatic NSCLC at the time of diagnosis

•Population is known to be highly symptomatic

•Baseline mean survival for met NSCLC in general is ~10 months

Early Palliative Care - NEJMAlthough clearly importance and necessary

I am proposing the findings from this study as they are presented

may have worrisome implications and create a new set of challenges for the PC

communityDr. Jeff Myers

April 28, 2012

“The innovative model of palliative care integrated in to the outpatient setting soon

after diagnosis of terminal cancer provides an alternate and efficacious approach to

reconcile the needs of patients for symptom management and psychosocial support while

simultaneously undergoing anticancer therapy”

Could PC provide care to every “terminal” patient/client?

SHOULD PC provide care to every “terminal” patient/client?

If we were to apply the two elements of how “terminal” seems to be defined for this study

i.e. incurable disease and one would not be surprised if death occurred in “X” number of months or years

to all patients for whom this definition applies, including those with non-malignant disease

the patient population would be is exponentially broadened

Could PC provide care to every patient or client living with an incurable illness and death from this illness in “X” months or

years would not be a surprise?

SHOULD PC provide care to every patient/client living with an incurable

illness and death from this illness in “X” months or years would not be a surprise?

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Total Number of Deaths projected to increase: By 20% in 10 years from 2010-11 to 2020-21. By 65% in 25 years from 2010-11 to 2035-36.

Actual and Projected Deaths in Ontario: 1996-2036

WE ARE HERE!!!

Could PC provide care to every patient/client living with an incurable illness

and death from this illness in “X” months or years would not be a surprise?

We simply do not have the PC human resources and therefore must be thoughtful in how

specialist PC is integrated in to models of care delivery

Journal of Clinical Oncology Provisional Clinical Opinion

Purpose: “ provide ASCO members with direction on issues that have been informed by recent data that should affect clinical practice ”

Only 4 PCO’s have been released since first introduced in 2009

Other JCO PCO’s“Testing for KRAS Gene Mutations in Patients With Metastatic Colorectal Carcinoma to Predict Response to Anti–Epidermal Growth Factor Receptor Monoclonal Antibody Therapy”

“Chronic Hepatitis B Virus Infection Screening in Patients Receiving Cytotoxic Chemotherapy for Treatment of Malignant Diseases”

“Epidermal Growth Factor Receptor (EGFR) Mutation Testing for Patients With Advanced Non–Small-Cell Lung Cancer Considering First-Line EGFR Tyrosine Kinase Inhibitor Therapy" Dr. Jeff Myers

April 28, 2012

Integration of Palliative Care in to Standard Oncologic Care

• While evidence clarifying optimal delivery of palliative care to improve pt outcomes is evolving, no trials to date have demonstrated harm to pts and CGs, or excessive costs, from early involvement of palliative care

• 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

The concern is further underscored if the word “oncologic” is replaced with any other field or clinical context for which a substantial proportion of the

patient population has incurable disease

eg. CHF, COPD, dementia, ESRDDr. Jeff Myers

April 28, 2012

Integration of Palliative Care in to Standard (insert specialty) Care

• Combined standard (insert specialty) care and palliative care should be considered early in the course of illness for any patient with (insert incurable dz) and/or high symptom burden

The current reality is “combined”, “shared” or “simultaneous” models of care delivery have yet to be explored

and endorsed as formally for other fields and clinical contexts as they

have for oncologyDr. Jeff Myers

April 28, 2012

Clinical Course - Dementia• Aim: Prospectively describe the clinical course

of pts with advanced dementia living in a LTCF

• Observational cohort study; 323 pts in 18 LTCF

• Prior to this, the understanding of the clinical course of advanced dementia based on retrospective or cross-sectional studies or included only hospitalized patients

Conclusions: 1) “Underscores the need to improve the

quality of palliative care in nursing homes in order to reduce the physical suffering of residents with advanced dementia who are dying.”

Clinical Course - Dementia

Conclusions: 2) “Our prospective study shows that

dementia is a terminal illness and furthers our knowledge of the clinical complications characterizing its final stage.”

This was the first time this statement was made

Clinical Course - Dementia

Clinical Course – DementiaLetter To The Editor

“Classifying all seniors affected by advanced dementia as terminally ill…

can become a gateway to therapeutic neglect."

Integration of Palliative Care in to Standard (insert specialty) Care

• Combined standard (insert specialty) care and palliative care should be considered early in the course of illness for any patient with (insert incurable dz) and/or high symptom burden

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WE ARE HERE!!!

For a person with an illness experience, what care elements

require palliation?

For a person with an illness experience, what care elements require specialist

hospice palliative care?

For a person with an illness experience, what care elements

require palliation?

For a person with an illness experience, what care elements require specialist

hospice palliative care?

? Dr. Jeff Myers April 28,

What do I believe to be the mainlesson from the HPC experience

in the cancer setting thus far?

“Early Hospice Palliative Care” IS NOT the right approach.

It should not be advocacy for integration of the HPC field earlier

in the illness trajectory…

It should be advocacy for earlier integration of both the

HPC philosophy and associated HPC-related clinical skills

Palliative Care Clinical ProtocolParticular attention was paid to:• Assessing physical and psychosocial symptoms • Establishing goals of care • Assisting with decision making regarding Tx • Coordinating care based on individual pt needs

What did palliative care clinicians do?

Early Palliative Care Illness Understanding

• 1/3 believed both their cancer to be curable and the goal of therapy was to “get rid of all of their cancer”

• A further 1/3 had discordant illness perceptions i.e. belief their cancer was “incurable” and simultaneous belief goal of therapy was ”get rid of all of their cancer”

Early Palliative Care Illness Understanding

• 1/3 believed both their cancer to be curable and the goal of therapy was to “get rid of all of their cancer”

• A further 1/3 had discordant illness perceptions i.e. belief their cancer was “incurable” and simultaneous belief goal of therapy was ”get rid of all of their cancer”

• EITHER Pts failed to fully appreciate the info OR

Clinicians were not providing clear and adequate info regarding the intent of therapy OR Both

Cancer: Symptom Control•Vast majority of oncologists have incorporated

the significant advances in control of chemo-related nausea into their practice

•Reflects significance of “QOL” in clinical trials•Advances have been included in federal and

nationally recognized guidelines•Oncologists recognize that failure to adequately

pre-medicate a pt receiving chemo would be a breach of accepted medical practice and ethics

Cancer: Symptom Control• National guidelines from federal agencies

and national consensus panels also exist for other cancer-related symptoms eg. pain

• Withholding meds, like analgesics, to adequately relieve cancer-related symptoms is as much a breach of accepted medical practice and ethics

• Symptom needs in general however continue to be unmet Dr. Jeff Myers

April 28, 2012

February 2012

• Editorial piece accompanying sub-study of NEJM article addressing impact on chemo

• Tells the story of a patient

February 2012

“While in the hospital, he and his family were served by outstanding palliative care physicians who had initiated discussions early on in the admission around resuscitation and intensive care use.”

February 2012

“We had previously discussed his overallprognosis and his personal goals in clinic, but we had not addressed every aspect of his advance directives, thinking that we had more time to discuss all of those questions.”

February 2012

“I would have thought that more conversations between oncologists and patients about the patients’ values and EOL wishes are better than fewer, but…”

It Takes A Village

“…studies have actually shown that, surprisingly, a majority of patients prefer to have discussions about advance directives with physicians that they do not know, such as an admitting doctor at the time of hospitalization.”

•“Patients explain this by characterizing their relationship with their oncologist as one that is about optimism:”

“You go to an oncologist to be cured not to be buried.”

•“Patients report feeling that their advance care preferences are outside the purview of their oncologists and that they do not want their oncologists to face a double-bind of working simultaneously to extend life while planning for death as well.” Dr. Jeff Myers

April 28, 2012

“…an important aspect of having a comprehensive care team with different HCPs (eg palliative care, primary care) is that our colleagues can serve a role of treatment brokers”

While the concept of “treatment brokers” is innovative, we must identify the HPC-related care elements that could have been provided by effectively functioning interprofessional oncology teams?

It Takes A Village

•“…suggests the possibility that, when we do not have support in providing end-of-life care, oncologists tend to do what we were trained to do: give chemotherapy.”

•“Oncologists need to accept the possibility that our patients might be better off if we do not try to do everything ourselves”

It Takes A Village

•“…suggests the possibility that, when we do not have support in providing end-of-life care, oncologists tend to do what we were trained to do: give chemotherapy.”

•“Oncologists need to accept the possibility that our patients might be better off if we do not try to do everything ourselves”

• I would propose this be reframed as “it takes a well educated and oncology village with access to and support provided by specialist HPC

It Takes A Village

It should be advocacy for earlier integration of both the

HPC philosophy and HPC-related clinical skills

EOL CareHospice & Palliative Care

Curative / Remissive Therapy

Presentation Death

CG Support &Bereavement

Current Model of Palliative Care Integration Dr. Jeff Myers April 28,

Proposed Model of Palliative Care Integration

Provision of HPCAcademic Mandate

Patient Volumes

Description of Patient

Levels of Care Expertise

Description of Provider Role

Care Setting

• Complex needs unresponsive to basic care or established protocols;• Require highly individualized care plans

• Experts in HPC; consults to secondary and primary level providers; Leaders in HPC research & education

• All care settings require at least access to tertiary level expertise generally hospital based

• HPC needs exceed those available from primary care;• Pt/families ability to cope is compromised

• Extensive HPC knowledge in HPC; model of care may be consult only to direct care; most often share care with primary team

• Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)

• Largest group of patients;• Most needs met through primary care providers (i.e. non-HPC specialists)

• Basic or primary level HPC related clinical skills (pain and Sx Mx; basic psycho-social care)

• All care settings

Tertiary Level

Secondary Level

HPC Expertise

Primary LevelHPC Expertise

What I encourage each one of us to reflect on from this past week and

change for next week and next year…

Contribute thoughtfully

Be willing to teach

Be precise & vigilant with your words

I am encouraging us to be thoughtful in:▫Contribution eg. “Care delivery models” ▫How we view consultations and referrals as

more than JUST patient/family care but as opportunities to educate our colleagues

▫“What can I teach, to whom, how and what will my response be next time?”

In the past few weeks do you remember hearing:

“This patient is palliative”

Did you respond?

“WE ARE ALL PALLIATIVE!!”Therefore the statement is meaningless unless it is contextualized so may as well skip the statement

and just provide the context Dr. Jeff Myers April 28,

Be precise and vigilant with your words

With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…

▫“What do you mean by ‘terminal’?”▫“What do you mean by ‘palliative’?”

“Oh you mean her illness is incurable.” “What’s her performance status and level of function as well as goals for her care?”

Precision With Our Words

With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…▫“Jeff, can I talk to you about a referral we’ve

made to pain clinic?”“Nope. But you can talk to me about a referral you’ve made to palliative care clinic. Did you tell the pt he was being seen in ‘palliative care clinic’?”

Precision With Our Words

Our time has come…• I encourage us to use this time wisely as ultimately

we cannot be the sole providers of HPC•Aim to move towards the day when our clinical time

is spent addressing “complex” systems•Until then ensure our clinical time is somehow

paired with teaching a colleague/learner “how to fish”

•Be vigilant - this is how we will build capacity Dr. Jeff Myers

April 28, 2012

What I encourage each one of us to reflect on from this past week and

change for next week and next year…

Contribute thoughtfully

Be willing to teach

Be precise & vigilant with your words

Jeff Myers MD, CCFP, MSEd Head – Palliative Care Consult Team

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