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

1. Carmelita Lawlor Lecture: HPCO Conference, April 28, 2012Our Time Has Come:Lessons Learned From The Cancer Experience Jeff Myers MD, CCFP, MSEd Head – Palliative Care Consult Team Co-Program Head – Patient and Family Support Program Odette Cancer Centre, Sunnybrook Health Sciences Centre W. Gifford-Jones Professor in Pain and Palliative Care Head and Associate Professor – Division of Palliative Care, Department of Family and Community Medicine Faculty of Medicine, University of Toronto

2. What do I believe to be the main lesson 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, 2012

3. 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

4. Dr. Jeff Myers April 28, 2012

5. 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 Dr. Jeff Myers April 28, 2012

6. Median Survival Standard care group = 8.9 months Palliative care group = 11.6 months (p=0.02) (despite receiving “less aggressive EOL care”) Dr. Jeff Myers April 28, 2012

7. Early Palliative Care - NEJM • 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 Dr. Jeff Myers April 28, 2012

8. Early Palliative Care - NEJM Although 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 community Dr. Jeff Myers April 28, 2012

9. Early Palliative Care - NEJM “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” . Dr. Jeff Myers April 28, 2012

10. Could PC provide care to every “terminal” patient/client? SHOULD PC provide care to every “terminal” patient/client? Dr. Jeff Myers April 28, 2012

11. 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 Dr. Jeff Myers April 28, 2012

12. 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? Dr. Jeff Myers April 28, 2012

13. Actual and Projected Deaths in Ontario: 1996-2036 WE ARE HERE!!!

14. 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 Dr. Jeff Myers April 28, 2012

15. Dr. Jeff Myers April 28, 2012

16. 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 Dr. Jeff Myers April 28, 2012

17. 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

18. 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 andCGs, 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 Dr. Jeff Myers April 28, 2012

19. 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, ESRD Dr. Jeff Myers April 28, 2012

20. Integration of Palliative Care in to Standard (insert specialty) Care • While evidence clarifying optimal delivery of palliative care to improve pt outcomes is evolving, no trials to date have demonstrated harm to pts andCGs, or excessive costs, from early involvement of palliative 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 Dr. Jeff Myers April 28, 2012

21. 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 oncology Dr. Jeff Myers April 28, 2012

22. Dr. Jeff Myers April 28, 2012

23. 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 Dr. Jeff Myers April 28, 2012

24. Clinical Course - Dementia Conclusions: • “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.” Dr. Jeff Myers April 28, 2012

25. Clinical Course - Dementia Conclusions: • “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 Dr. Jeff Myers April 28, 2012

26. Clinical Course – DementiaLetter To The Editor “Classifying all seniors affected by advanced dementia as terminally ill… can become a gateway to therapeutic neglect." Dr. Jeff Myers April 28, 2012

27. Integration of Palliative Care in to Standard (insert specialty) Care • While evidence clarifying optimal delivery of palliative care to improve pt outcomes is evolving, no trials to date have demonstrated harm to pts andCGs, or excessive costs, from early involvement of palliative 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 Dr. Jeff Myers April 28, 2012

28. WE ARE HERE!!!

29. 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, 2012

30. 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? ALL ? Dr. Jeff Myers April 28, 2012

31. What do I believe to be the main lesson from the HPC experience in the cancer setting thus far? “Early Hospice Palliative Care” IS NOT the right approach. Dr. Jeff Myers April 28, 2012

32. It should not be advocacy for integration of the HPC field earlier in the illness trajectory… Dr. Jeff Myers April 28, 2012

33. 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 Dr. Jeff Myers April 28, 2012

34. Early Palliative Care - NEJM What did palliative care clinicians do? Palliative Care Clinical Protocol Particular 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 Dr. Jeff Myers April 28, 2012

35. Dr. Jeff Myers April 28, 2012

36. Dr. Jeff Myers April 28, 2012

37. Dr. Jeff Myers April 28, 2012

38. 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” Dr. Jeff Myers April 28, 2012

39. 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 Dr. Jeff Myers April 28, 2012

40. Dr. Jeff Myers April 28, 2012

41. 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 Dr. Jeff Myers April 28, 2012

42. 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

43. February 2012 • Editorial piece accompanying sub-study of NEJM article addressing impact on chemo • Tells the story of a patient Dr. Jeff Myers April 28, 2012

44. 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.” Dr. Jeff Myers April 28, 2012

45. February 2012 “We had previously discussed his overall prognosis 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.” Dr. Jeff Myers April 28, 2012

46. 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…” Dr. Jeff Myers April 28, 2012

47. 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.” Dr. Jeff Myers April 28, 2012

48. “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

49. It Takes A Village “…an important aspect of having a comprehensive care team with differentHCPs (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? Dr. Jeff Myers April 28, 2012

50. 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” Dr. Jeff Myers April 28, 2012