jeff myers md, ccfp, msed head – palliative care consult team
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Carmelita Lawlor Lecture: HPCO Conference, April 28, 2012 Our 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 - PowerPoint PPT PresentationTRANSCRIPT
Carmelita Lawlor Lecture: HPCO Conference, April 28, 2012
Our Time Has Come:Lessons Learned From The Cancer Experience
Jeff Myers MD, CCFP, MSEdHead – Palliative Care Consult TeamCo-Program Head – Patient and Family Support ProgramOdette Cancer Centre, Sunnybrook Health Sciences CentreW. Gifford-Jones Professor in Pain and Palliative CareHead and Associate Professor – Division of Palliative Care, Department of Family and Community MedicineFaculty of Medicine, University of Toronto
What do I believe to be the mainlesson 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
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
Dr. Jeff Myers April 28,
2012
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
Median SurvivalStandard 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
•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
Early Palliative Care - NEJM
Dr. Jeff Myers April 28,
2012
Early Palliative Care - NEJMAlthough 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
communityDr. Jeff Myers
April 28, 2012
“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”
.
Early Palliative Care - NEJM
Dr. Jeff Myers April 28,
2012
Could PC provide care to every “terminal” patient/client?
SHOULD PC provide care to every “terminal” patient/client?
Dr. Jeff Myers April 28,
2012
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
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
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Total Number of Deaths projected to increase: By 20% in 10 years from 2010-11 to 2020-21. By 65% in 25 years from 2010-11 to 2035-36.
Actual and Projected Deaths in Ontario: 1996-2036
WE ARE HERE!!!
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
Dr. Jeff Myers April 28,
2012
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
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
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 and CGs, 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
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, ESRDDr. Jeff Myers
April 28, 2012
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 and CGs, 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
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 oncologyDr. Jeff Myers
April 28, 2012
Dr. Jeff Myers April 28,
2012
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
Conclusions: 1) “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.”
Clinical Course - Dementia
Dr. Jeff Myers April 28,
2012
Conclusions: 2) “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
Clinical Course - Dementia
Dr. Jeff Myers April 28,
2012
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
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 and CGs, 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
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WE ARE HERE!!!
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
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
What do I believe to be the mainlesson 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
It should not be advocacy for integration of the HPC field earlier
in the illness trajectory…
Dr. Jeff Myers April 28,
2012
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
Early Palliative Care - NEJM
Palliative Care Clinical ProtocolParticular 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
What did palliative care clinicians do?
Dr. Jeff Myers April 28,
2012
Dr. Jeff Myers April 28,
2012
Dr. Jeff Myers April 28,
2012
Dr. Jeff Myers April 28,
2012
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
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
Dr. Jeff Myers April 28,
2012
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
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
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
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
February 2012
“We had previously discussed his overallprognosis 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
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
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
•“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
“…an important aspect of having a comprehensive care team with different HCPs (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?
It Takes A Village
Dr. Jeff Myers April 28,
2012
•“…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”
It Takes A Village
Dr. Jeff Myers April 28,
2012
•“…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”
• I would propose this be reframed as “it takes a well educated and oncology village with access to and support provided by specialist HPC
It Takes A Village
Dr. Jeff Myers April 28,
2012
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 HPC-related clinical skills
Dr. Jeff Myers April 28,
2012
EOL CareHospice & Palliative Care
Curative / Remissive Therapy
Presentation Death
CG Support &Bereavement
Current Model of Palliative Care Integration Dr. Jeff Myers April 28,
2012
Proposed Model of Palliative Care Integration
Provision of HPCAcademic Mandate
Patient Volumes
Description of Patient
Needs
Levels of Care Expertise
Description of Provider Role
Care Setting
• Complex needs unresponsive to basic care or established protocols;• Require highly individualized care plans
• Experts in HPC; consults to secondary and primary level providers; Leaders in HPC research & education
• All care settings require at least access to tertiary level expertise generally hospital based
• HPC needs exceed those available from primary care;• Pt/families ability to cope is compromised
• Extensive HPC knowledge in HPC; model of care may be consult only to direct care; most often share care with primary team
• Required in all care settings (home, acute care, LTC, CCC ambulatory clinics)
• Largest group of patients;• Most needs met through primary care providers (i.e. non-HPC specialists)
• Basic or primary level HPC related clinical skills (pain and Sx Mx; basic psycho-social care)
• All care settings
`
Tertiary Level
Secondary Level
HPC Expertise
Primary LevelHPC Expertise
What I encourage each one of us to reflect on from this past week and
change for next week and next year…
Contribute thoughtfully
Be willing to teach
Be precise & vigilant with your words
Dr. Jeff Myers April 28,
2012
I am encouraging us to be thoughtful in:▫Contribution eg. “Care delivery models” ▫How we view consultations and referrals as
more than JUST patient/family care but as opportunities to educate our colleagues
▫“What can I teach, to whom, how and what will my response be next time?”
Dr. Jeff Myers April 28,
2012
In the past few weeks do you remember hearing:
“This patient is palliative”
Dr. Jeff Myers April 28,
2012
In the past few weeks do you remember hearing:
“This patient is palliative”
Did you respond?
Dr. Jeff Myers April 28,
2012
In the past few weeks do you remember hearing:
“This patient is palliative”
“WE ARE ALL PALLIATIVE!!”Therefore the statement is meaningless unless it is contextualized so may as well skip the statement
and just provide the context Dr. Jeff Myers April 28,
2012
In the past few weeks do you remember hearing:
“This patient is palliative”
Be precise and vigilant with your words
Dr. Jeff Myers April 28,
2012
With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…
▫“What do you mean by ‘terminal’?”▫“What do you mean by ‘palliative’?”
“Oh you mean her illness is incurable.” “What’s her performance status and level of function as well as goals for her care?”
Precision With Our Words
Dr. Jeff Myers April 28,
2012
With vigilance and respect, seek clarification, correct inaccuracies & teach colleagues, learners, family members, friends…▫“Jeff, can I talk to you about a referral we’ve
made to pain clinic?”“Nope. But you can talk to me about a referral you’ve made to palliative care clinic. Did you tell the pt he was being seen in ‘palliative care clinic’?”
Precision With Our Words
Dr. Jeff Myers April 28,
2012
Our time has come…• I encourage us to use this time wisely as ultimately
we cannot be the sole providers of HPC•Aim to move towards the day when our clinical time
is spent addressing “complex” systems•Until then ensure our clinical time is somehow
paired with teaching a colleague/learner “how to fish”
•Be vigilant - this is how we will build capacity Dr. Jeff Myers
April 28, 2012
What I encourage each one of us to reflect on from this past week and
change for next week and next year…
Contribute thoughtfully
Be willing to teach
Be precise & vigilant with your words
Dr. Jeff Myers April 28,
2012