Supportive/Palliative Care For The Woman With Cancer

Michael L. Pearl, MD, FACOG, FACSProfessor and Director, Division of Gynecologic Oncology

Director, Women’s Cancer ServicesStony Brook Medicine

Objectives

At the completion of this presentation, the participant will be able to:

– Define palliative care– Describe the role of palliative care in contemporary

management of the woman with cancer– Provide several examples of palliative care– Distinguish between palliative care and hospice care – Appraise the New York Palliative Care Information Act

Occasionally, I am a surgical consultant for Ethicon

WHY?

Introduction

• It seems appropriate to have a talk about palliative care at the END…

• In reality, this talk should be one of the FIRST talks!

Palliative Care

“If you’ve never heard of palliative care, you’re not alone. In a recent survey, only 24% of people said they were familiar with the term. Palliative care isn’t nearly as well known as, say, hospice care; in fact, people often confuse the two. Its use is growing fast, however, and 59% of hospitals with more than 50 beds now have palliative-care programs. Hospitals like this type of care because it appears to be cost-effective and may improve health outcomes. Patients — once they know about it — like it because it can make them feel better.”

The Washington Post, 3/28/11

Definition of “Palliative”

pal·li·a·tive • adjective /’palē,ātiv/  /’palēətiv/ 

– (of a treatment or medicine) Relieving pain or alleviating a problem without dealing with the underlying cause • short-term, palliative measures had been taken

• noun /’palē,ātiv/  /’palēətiv/ palliatives, plural– A remedy, medicine, etc., of such a kind

Palliative Care:Traditional View

“Active Treatment”

PalliativeCare

DEATH

Palliative Care:Traditional View

“Recurrent ovarian cancer is seldom curable. Second-, third-, or even fourth-line chemotherapy is often administered in a palliative fashion, as a means of diminishing symptoms and prolonging life.”

http://emedicine.medscape.com/article/270646-overview

Palliative Care:Traditional View

•Ms. Jones has Stage IIIC EOC– Cytoreductive surgery, followed by Taxol/Carboplatin– Recurrence # 1 treated with Topotecan– Progression # 1 treated with Doxil– Progression # 2 treated with Gemzar/CDDP– SBO, surgery unsuccessful – Pain, progressive weakness, altered mental status– Admitted to Hospice for 9 days before dying

•Survival: 43 months from diagnosis

Palliative Care:Contemporary View

Cure/Life-prolongingIntent

Palliative/Comfort Intent

Bereavement

DEATH

CMS Definition Of Palliative Care:Contemporary View

“Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”

73 FR 32204, June 5, 2008Medicare Hospice Conditions of Participation – Final Rule

Palliative Care:Contemporary View

•Ms. Jones has Stage IIIC EOC– Cytoreductive surgery, followed by Taxol/Carboplatin

• Referred to Palliative Care Team before discharge– Palliative care physician, clinical pharmacist, social worker, attorney,

occupational therapist, beautician, nutritionist, chaplain – Recurrence # 1 treated with Topotecan

• Referred to Palliative Care Team before starting chemotherapy– Progression # 1 treated with Doxil

• Palliative Care Team actively involved– Progression # 2, chemotherapy stopped

• Palliative Care Team actively involved– SBO, no surgery, G-tube placed, Hospice Care instituted– Pain and other symptoms well-controlled, died at home 5 weeks

later•Survival: 49 months from diagnosis

How Does Palliative Care Differ From Hospice Care*?

• Palliative Care is appropriate at any time during management of a serious illness. It can be provided at the same time as, and in addition to, life-prolonging treatment. There are no prognostic requirements and no need to choose between management approaches (palliative care vs. curative/life-prolonging care).

• Hospice Care is a form of palliative care that provides care for those at the end of their life. According to CMS rules, patients must have a 2 MD-certified prognosis of <6 months and give up insurance coverage for curative/life prolonging treatment in order to be eligible.

*Hospice and Palliative Medicine is a nationally-recognized subspecialty with Board Certification available through the American Board of Medical Specialties.

http://www.aahpm.org

Evolving Model Of Palliative Care

Palliative Care Team

• Usually a team of experts, including palliative care physicians, nurses and social workers. Chaplains, massage therapists, pharmacists, nutritionists and others may also be part of the palliative care team. Working together with the attending physician, the palliative care team provides:– Close communication – Expert management of pain and other symptoms – Help navigating the healthcare system – Guidance with difficult and complex treatment choices – Emotional and spiritual support for the patient and family

Palliative Care Goals

• While palliative care may seem to offer a broad range of services, the goals of palliative treatment are concrete:– relief from suffering, – treatment of pain and other distressing symptoms– psychological and spiritual care– a support system to help the patient live as actively as

possible– and a support system to sustain and rehabilitate the patient's

family

Walsh D, et al. J Pain Symptom Manage 1994;9(2): 109-.

Examples of Palliative Care

• Clinical pharmacist helps control chemotherapy-induced symptoms (e.g., nausea/vomiting, fatigue, mouth sores)

• Social worker assists with advance directives and accessing community resources (e.g., transportation)

• Weekly spiritual visits (e.g., chaplain, minister, rabbi, imam….)

• Massage therapist, cosmetician, physical therapist, nutritionist

Why Palliative Care?

Palliative Care Is Beneficial

• Overall, patient satisfaction is markedly superior with palliative care compared to usual care

• Palliative care superior for:– Care/setting concordant with patient preference– Emotional/spiritual support– Information/communication– Care at time of death– Access to community services– Well-being/dignity– Pain control– PTSD symptoms

Casareti et al. J Am Geriatr Soc 2008;56:593-99

Palliative Care Is Beneficial

• Recall of a conversation regarding goals and prognostication was associated with:– Better quality of dying and death– Lower risk of complicated grief and

bereavement– Less “aggressive” care– Lower costs of care

Zhang et al. Arch Int Med 2009;169:480-488Wright et al. JAMA 2008;300:1665-1673

Prospective, multicenter study of 332 seriously ill cancer patients

Temel et al. N Engl J Med 2010;363:733-742

Palliative Care Improves Survival

• Randomized, prospective, controlled study of patients with newly diagnosed non-small cell lung cancer

• Integrated palliative care consult team (PCCT) with standard oncologic care vs. standard oncologic care:– PCCT met with patient & family within 3 wks, then at least every 6 wks

• Pain and symptom management• Psychosocial and spiritual support• Assistance with treatment choices• Help in planning for care in the community• Bereavement support and referral

• Early palliative care led to significantly:– Improved quality of life and mood in pts. with metastatic disease– Less aggressive care but significantly longer median survival

• 11.6 vs. 8.9 months

Palliative Care Reduces Cost

• Substantial data demonstrates decreased cost across settings, regions, institutional and delivery models

• Why?– Talking openly and realistically with patients, families

and treating physicians leads to more conservative choices

– Allows provision of higher quality and more satisfactory care in more appropriate and, often, less costly settings

And, Yes, Palliative Care Includes Hospice Care

• Home• Comfort• Sense of

completion• Saying goodbye• Life-review

Themes for a “good” death

“Hey, great death!”

Palliative Care Allows People To Die at Home

85

57

91 87

0

20

40

60

80

100

% satisfied with services % died at home

Usual Medicare home care Palliative care intervention

Brumley et al. The Permanente Journal 2003;7:7-12

Outcomes among patients who died from CHF/COPD/Cancer Palliative Care vs. Usual Care, 1999-2000

New York Palliative Care Information Act

“If a patient is diagnosed with a terminal illness or condition, the patient's attending health

care practitioner shall offer to provide the patient with information and counseling regarding

palliative care and end-of-life options appropriate to the patient, including but not limited to:

the range of options appropriate to the patient; the prognosis, risks and benefits of the

various options; and the patient's legal rights to comprehensive pain and symptom

management at the end of life.  The information and counseling may be provided orally or

in writing.  Where the patient lacks capacity to reasonably understand and make informed

choices relating to palliative care, the attending health care practitioner shall provide

information and counseling under this section to a person with authority to make health

care decisions for the patient.  The attending health care practitioner may arrange for

information and counseling under this section to be provided by another professionally

qualified individual.”

NY Public Health Law, Section 2997-C

New York Palliative Care Information Act

“If a patient is diagnosed with a terminal illness or condition, the patient's attending health care practitioner shall offer to provide  the patient  with  information  and counseling regarding palliative care and end-of-life options appropriate to the patient…”

• Specific for patients who are predicted to have less than 6 months to live (“terminal”)

• Requires that a physician be able and willing to make that prediction (prognosticate)

• Wording suggests palliative care and hospice care are identical

Potential Pitfalls

New York Palliative Care Information Act

• The presence of chronic disease(s) or symptoms or functional impairments that persist but may also fluctuate

• The symptoms or impairments resulting from the underlying irreversible disease require formal or informal care and can lead to death

• Does not have a time component

Components of “End Of Life”

NIH State-of-the-Science Conference Statement on Improving End-of-Life Care; http://consensus.nih.gov

New York Palliative Care Information Act

• Population-based cohort of 233 cancer patients at onset of terminal phase

• Prospective evaluation of clinical estimate of survival

• Treating physicians overestimated duration of survival– 25% accurate within 1 month– 23% underestimated survival– 52% overestimated survival (2/3 of incorrect

estimates)

Cancer 1999:86(1);170-176

No crystal ball!

New York Palliative Care Information Act

Cure/Life-prolongingIntent

Palliative/Comfort Intent

Bereavement

DEATH

“Active Treatment”

PalliativeCare

DEATH

Palliative care is more than just hospice care

New York Palliative Care Information Act

“The attending health care practitioner may arrange for information and counseling under this section to be provided by another professionally qualified individual.”

New York Palliative Care Information Act

How Can You Get Palliative Care?

• Ask your doctor • Call your hospital• Speak to other patients• Internet resources

Palliative Care Resources

• American Association of Hospice and Palliative Medicine. www.aahpm.org

• Center to Advance Palliative Care. www.capc.org

• National Hospice and Palliative Care Organization. www.nhpco.org

• www.palliativedoctors.org• www.getpalliativecare.org• Many, many others…….

Thank You