Palliative Care. Tom Smith Thomas Palliative Care Program Massey Cancer Center Virginia Commonwealth University Health System Richmond, Virginia firstname.lastname@example.org. *“It’s hard to define it, but you know it when you see it.” -George Parker, MD. Objectives and plan.
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Thomas Palliative Care Program
Massey Cancer Center
Virginia Commonwealth University Health System
*“It’s hard to define it, but you know it when you see it.”
-George Parker, MD
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….
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 -- EducationalMeier, 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.RCT 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
-29% of all
-64% of all
Symptoms are improved by PC consultation or transferESAS 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
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.
Massey Cancer Center