Referrals to Palliative Care Services
Medical Oncology perspectiveKavi Capildeo MBBS FRCP(Edin) DM
SMO, Eastern Regional Health Authority
Cancer as a cause of mortality
Cancer: W.H.O. estimates– ≈ 40% preventable- ∴ ≈ 60% are not– ≈ 40% curable- ∴ ≈ 60% are not
Trinidad and Tobago– 3rd leading cause of death
(after cardiovascular disease and diabetes)
Death from cancer generally not sudden/instantaneous
http://www.who.int/cancer/WHA_cancer_presentation_final.pdf Accessed Oct 16, 201140% www.cso.gov.tt
Cancer mortality in Trinidad and Tobago
Jan 1997- Dec 2006: 12616 deaths – Male: 6876 Female: 5740
Top 5 causes of cancer death– Prostate 20%– Breast 11%– Colorectal 10%– Bronchus and Lung 8%– Leukemia 6%
Elizabeth Quamina Cancer Registry
Death
High
LowTime
Function
Death
High
LowTime
Function
Gradual decline e.g.Dementia, frailty
Death
High
LowTime
Function
Rapid decline eg. Cancer
Palliative care - trajectories
Erratic decline eg organ failure
Source: NHS Scotland
Oncology clients and palliative careWhat palliative care needs can oncologist meet?
When should client be referred for palliative care?– What palliative care services exist in T&T?– Adequate? If not, how to fix system?
When can patients receiving palliative care benefit from intervention by oncologists?
Oncology services in T&T
National Radiotherapy Centre
Regional clinics: ERHA, SWRHA, Tobago
2 private centres
Radiation and medical oncologists
Oncology nurses
Social workers
Pharmacists
Palliative care within Oncology ClinicsEvaluation of pain and other symptoms
Pain medications, other drug therapies
Psychosocial support: Medical Social Worker
Oncologic intervention with palliative intent– Radiation – Chemotherapy– Endocrine therapy– Targeted therapies– Palliative surgery
Palliative care in oncology clinic setting: limitations
Limited community outreach
No care facility for terminally ill in MoH service
Staff have other duties– Radiation planning/delivery, chemo etc– No staff exclusively assigned to
palliative/supportive care
Patient/family may not perceive clinic as source of supportive care (or even interested)– “doctors can’t do anything more”
No safety net?
Fall from clinic system→ a hard landing for the client?
? Pressure to maintain status quo with continued efforts at chemo/RT
Palliative care services in TT
3 hospices– 1 exclusively for cancer, 1 for HIV/AIDS– All NGO based– All in POS
Community-based, nurse-led service– St. Andrew/St. David only
GPs with experience in palliative care– Private sector– ? <10
INCB and Trinidad
United Nations agency
Regulates international sale of narcotic drugs
T&T- severe limits
Chronic shortages
Fentanyl
Hydrom
orphone
Meth
adone
Morp
hine
Oxycodone
Pethid
ine
0
50000
100000
150000
200000
250000
300000
Canada g per million pop
Trinidad g per million
2011 drug alloca-tions in grams(expressed as quantity per mil-lion population)
http://www.incb.org/pdf/technical-reports/narcotic-drugs/2010/NAR_2010_EFS_Part3.pdf , ac-cessed Oct 15 2011Quantities per 1 million population calculated using 2009 World Bank population estimates
Why?
Palliative care in TTLimitations and challenges
Community-based, public-sector services– Absent in most areas– MoH support required
Hospice facilities
Outpatient clinics
Personnel
Training and education
Equipment and drugs
Public awareness
Oncology and Palliative Care
Both multidisciplinary, client centred
Overlapping objectives– Quality of life and death– Symptom relief– Supportive care
Complementary roles
Kaplan–Meier Estimates of Survival According to Study Group.
Temel JS et al. N Engl J Med 2010;363:733-742.
Randomized trial of early palliative care referral vs standard care in pts with metastatic NSCLC•Higher QOL scores•Improved mood•Improved survival•Less aggressive end-of-life care
Appropriate referralsOncology staff, clients, families– Awareness of available services– Timely referral – Aware of referral pathways/protocols
Palliative care services– Refer when appropriate for intervention to
control symptomsPalliative RT: bone pain, SVCO, etc
Systemic treatments
DEFINING PALLIATIVE CAREWorld Health Organisation
Approach to care that ↑ QoL of patients/ families with problems associated with life threatening illness Prevention and relief of suffering– early identification and impeccable assessment
and treatment :pain other problems
– physical– psychological– spiritual
Palliative care- whose responsibility?
Palliative care is the responsibility of all health and social care professionals delivering care
(NICE, 2004)
Specialist palliative care services
“When they lack the skills, confidence or expertise to cope adequately with a problem…”
• Uncontrolled/complicated symptoms
• Uncontrolled anxiety or depression
• Complex emotional needs involving children, family or carers
• Complex issues relating to physical and human environment (i.e home, finances etc)
• Unresolved spiritual issues around self worth, loss of meaning and hope (may include euthanasia issues)
When should a Service refer to Specialist Palliative Care?
Bradford & AiredaleManaged Clinical NetworkPalliative / End of Life CareEducation Programme
21
Specialist Palliative Care Provision
Bradford & AiredaleManaged Clinical NetworkPalliative / End of Life CareEducation Programme
Three triggers for Supportive/ Palliative Care
1. The surprise question: ‘Would you be surprised if this patient were to die
in the next 6-12 months?’ 2. Choice:
The patient with advanced disease makes a choice for comfort care
3. Clinical indicators:Specific to each of the three main end of life groups - cancer, organ failure, elderly frail/dementia
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Supportive and Palliative Care Indicators tool
(1) Ask
Does this patient have an advanced long term condition, a new diagnosis of a progressive life limiting illness, or both?
Would you be surprised if this patient died in the next 6-12 months?
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Supportive and Palliative Care Indicators Tool
(2) Look for one or more general clinical indicators
Performance status poor or deterioratingProgressive weight loss (>10%) over past 6 months2 or more unplanned admissions in last 6 monthsPatient is in a nursing /care home, or needs more care at home
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Cancer- palliative care indicators
Performance status deteriorating due to metastatic cancer and/or comorbidities
Persistent symptoms despite optimal palliative oncology treatment
Too frail for oncology treatment
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Clinical indicators for terminal careQ1. Could this patient be in the last days
of life?
Confined to bed/chair or unable to self care
Difficulty taking oral fluids or not tolerating artificial feeding/hydration
No longer able to take oral medication
Increasingly drowsy
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Clinical indicators for terminal care
Q2. Was this patient’s condition expected to deteriorate in this way?
Q3. Is further life-prolonging treatment inappropriate?
Q4. Have potentially reversible causes of deterioration been excluded?
Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
Summary
Palliative care for patients with cancer– Responsibility of all involved HCWs– Teamworking to improve quality of life, end-of-
life care– Appropriate and timely referral to specialist
palliative care services (where available)– Gaps in system need to be addressed