Palliative Care. Tom Smith Thomas Palliative Care Program Massey Cancer Center Virginia Commonwealth University Health System Richmond, Virginia [email protected] *“It’s hard to define it, but you know it when you see it.” -George Parker, MD. Objectives and plan.
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Felson’s Law: to steal ideas from one person is plagiarism; to steal from many is research.
% of 5176 patients reporting moderate to severe pain between days 8-12 of hospitalization:
colon cancer 60%
liver failure 60%
lung cancer 57%
MOSF + cancer 53%
MOSF + sepsis 52%
Also: 20% of Medicare patients starting NEW chemo with 2 weeks of death
Hospice referrals coming later, if at all….
Health care professionals weeks of death
Lack of time?
Lack of training
Lack of interest
Lack of reimbursement
Hard to get/stay involved (“burnout”)
It’s just hard
Don’t have high expectations
Suffering is good
Be a good patient
If I tell the doctor…
She/he will give up on me
It means that the cancer is growingWhy the mismatch between what we want, what could be provided?
Why we did it -- Educational weeks of deathMeier, Morrison & Cassel. Ann Intern Med 1997;127:225-30.Deficiencies in medical education. Billings & Block JAMA 1997;278:733.
1/8th of Medicare $ spent in last 60 days of life
New drugs: Oxaliplatin, Erbitux $4000/cycle; Avastin $100,000/12 months, adds 2 months life
“Medicare doesn’t pay me enough to talk to people.”
Du Pen SL, et al. 1970-2003RCT of 81 ptsAlgorithm of AHCPR guidelinesvs standard practiceJ Clin Oncol 1999;17:361-70Smith TJ et al. The Cancer Pain Trial. Randomized trial of intra-spinal pain medications vs usual care. JCO 2002:20:4040-49.
Oncology patient pain management is not optimal, and can be improved by paying attention, following algorithm, ….
Intervention: a nurse coordinator in charge so that families had someone to call 24/7
Pitorak E, J Pall Med2003;6: 645-655
Source: Post-Discharge/Death Family Satisfaction Interviews, Mount Sinai Hospital, New York City
100% Satisfied Following Their Loved Ones Death With:
Disease CourseWhere do hospital-based PC programs focus?
-29% of all
-64% of all
Symptoms are improved by PC consultation or transfer Satisfied Following Their Loved Ones Death With:ESAS scale 0-330 pts with at least 2 consult days and symptoms >0Khatcheressian J, et al. Oncology September 2005
Khatcheressian J, et al. Oncology September 2005
Patients said that it helped
Significantly improved pain control with IDDS (p=0.055 as randomized; p=0.007 as treated).
OS PS, p<0.05
Be prepared for the long haul measures
Have “the talk”:
High volume, expert
Walker Percy MD, Love in the Ruins 1971
NP makes rounds to identify patients for consults, MD-MD
Earlier transfer of dying patients may improve
EOL care and reduce cost.
“Off-loads” ICUs and avoids diversion.