2. Objectives
ďDiscuss the paradigm shift of palliative care in oncology
ďRecognize benefits of palliative care in cancer care
ďIdentify challenges, opportunities and potential
solutions to expand palliative care in Pennsylvania.
5. Palliative Care, defined
âPalliative 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.â
~as defined by United States Department of health and Human Services (HHS)
Centers for Medicare & Medicaid Services (CMS), the National Quality
Forum(NQF) and National Consensus Project
6. Palliative care Consultation
ďSerious illness with any Prognosis
ďGoals can be curative or palliative
ďInterdisciplinary team
ďIn hospital consultation, outpatient
clinics
ďCovered by insurance like other
specialists, may include copay
ďRequired physician or NP visit
ďRare in-home visits
Palliative Care via Hospice
ďSerious illness with 6 month or less
prognosis
ďPalliative goals only (not life-
prolonging)
ďInterdisciplinary team
ďMajority in home care, some inpatient
hospice
ď100% covered by most insurances when
prognosis certified
ďPhysician/NP visit not required but
involved in plan of care
7. âAll hospice is palliative care but palliative care is not all hospiceâ
âPalliative care is both a philosophy and a method of deliveryâ
8. Palliative Care Is
ďźExcellent, evidence-
based
medical treatment
ďźVigorous care of
pain and symptoms
throughout illness
ďźCare that patients
want at the same time
as efforts to cure or
prolong life
Palliative Care Is NOTNOT
ď Not âgiving upâ on aNot âgiving upâ on a
patientpatient
ď Not in place ofNot in place of
curative or life-curative or life-
prolonging careprolonging care
ď Not the same asNot the same as
hospicehospice
Slide courtesy of Kathy Selvaggi, MS MD Butler Health
9. Benefits of PC in Serious Illness
ďKavalieratos et al, JAMA 2016: Systematic review
and meta-analysis of 43 RCTs in palliative care vs
usual care: inpatient and outpatient (14)
ďImproved quality of life and symptom burden
ďNo change in survival
ďImprovements in advance care planning, patient and
caregiver satisfaction, and lower health care utilization
Kavalieratos, Dio, Jennifer Corbelli, Di Zhang, J. Nicholas Dionne-Odom, Natalie C. Ernecoff, Janel
Hanmer, and others, âAssociation Between Palliative Care and Patient and Caregiver Outcomes: A
Systematic Review and Meta-Analysisâ, JAMA, 316 (2016), 2104â14 Nov 2016
10. Benefits of Outpt PC in Serious Illness
Davis, et al A of Pall Med 2015: Review of 62 studies on
PC in ambulatory and home care (28 RCTs, )
ďImprovements in Depression, patient/caregiver
Quality of life, patient and family satisfaction, caregiver
burden
ďReduced aggressive care at EOL, Increased advanced
directives,
ďReduced hospital length of stay and hospitalizations,
reduction in overall cost of care
Davis, Mellar P., Jennifer S. Temel, Tracy Balboni, and Paul Glare, âA Review of the Trials Which Examine Early Integration
of Outpatient and Home Palliative Care for Patients with Serious Illnessesâ, Annals of Palliative Medicine, 4 (2015), 99â121
11. Benefits of PC in Cancer Care
ďSymptom improvement: Depression
ďPatient reported outcomes: Improved Quality of life
and patient satisfaction
ďResource allocation: Less Chemo at EOL, Increased
enrollment and length of use of hospice at EOL
ďSurvival: Improved (in two studies)
ďNo adverse outcomes noted.
Ferrell, Betty R., Jennifer S. Temel, Sarah Temin, Erin R. Alesi, Tracy A. Balboni, Ethan M. Basch, and
others, âIntegration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology
Clinical Practice Guideline Updateâ, Journal of Clinical Oncology, 2016, JCO.2016.70.1474
12. Benefits of PC in Cancer Care, cont.
Temel et al:
ďPts with newly diagnosed Stage IV NSCLCa at MGH
with standard monthly outpatient pall care
ďImproved QOL, survival(2.7mo) & mood by 8 weeks 1
ď 2.5mo = median benefit of new solid tumor txs introduced 2002-144
ďLess aggressive EOL care (4th
line chemo), hospice referral earlier
and longer duration 1
ďImproved prognostic awareness ď less chemo at EOL2
ďLess chemotherapy at EOL(within 60 days), more time without
chemo before death, more enrollment in hospice > 1 week3
1. Temel, et alâEarly Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancerâ, The New England Journal of Medicine, 363 (2010), 733â42
2. Temel, et al âLongitudinal Perceptions of Prognosis and Goals of Therapy in Patients with Metastatic Non-Small-Cell Lung Cancer: Results of a
Randomized Study of Early Palliative Careâ, Journal of Clinical Oncology(2011), 2319â26
3. Greer, et al âEffect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients with Metastatic Non-Small-Cell Lung Cancerâ, Journal
of Clinical Oncology (2012),
4. Fojo, Tito, Sham Mailankody, and Andrew Lo, âUnintended Consequences of Expensive Cancer TherapeuticsâThe Pursuit of Marginal Indications and a
Me-Too Mentality That Stifles Innovation and Creativity: The John Conley Lectureâ, JAMA OtolaryngologyâHead & Neck Surgery, 140 (2014),
13. Benefits of PC in Cancer Care, cont.
Bakitas et al ENABLE I-III trials:
ď In person & phone nurse-led PC support for patients
with advanced cancer of various types, prognosis 6-24
mo, in New Hampshire
ďII: Less depression, improved QOL
ďIII: 15% difference in one-year survival when pall care was started
three months earlier
Bakitas, Marie A., Tor D. Tosteson, Zhigang Li, Kathleen D. Lyons, Jay G. Hull, Zhongze Li, and others,
âEarly Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE
III Randomized Controlled Trialâ, Journal of Clinical Oncology, 2015, JCO.2014.58.6362
14. Palliative Care in Private Oncology Clinic
ďPalliative care clinic integrated into an office-
based oncology practice
ďMeasurement of symptom burden- ESAS scale
ď21% decrease in symptom burden (ESAS 49.3 ď 39)
ďOncology Provider satisfaction: 9/10
ďOncologists time saved in 1 year: 4 weeks (162
hours)
Muir, J. C et al âIntegrating Palliative Care into the Outpatient, Private Practice Oncology Setting.â Journal of Pain and
Symptom Management 40, no. 1 (July 2010)
Modification of Original Slide by Dr. K Selvaggi
15. ďMeisenberg et al:
ď340 visits were recorded for 330 unique patients
during 11 months of a NP Supportive Care Clinic
ďSame day / next day appointments with NP were
arranged for 62% / 25% of patients
ďAdmissions for symptoms decreased by 31%
ď66 ED visits avoided
Symptom management in Oncology Clinic
Meisenberg, Barry R., Lynn Graze, and Catherine J. Brady-Copertino. âA Supportive Care Clinic for Cancer
Patients Embedded within an Oncology Practice.â The Journal of Community and Supportive Oncology 12, no. 6
(June 2014): 205â8.
16. Benefit of Patient Reported
Outcomes Management
Basch et. al
ď766 adults with metastatic cancers receiving chemotherapy
randomized to report symptoms through a computerized
patient reporting portal or usual care
ďPatients using the PRO portal had:
ď 5 mo longer survival(26 vs 31.2)
ď 2 mo longer tolerance of chemo (8.2 vs 6.3)
ďLess decline in quality of life
ďLess ED and hospitalization
Basch, E et.al âOverall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer
Treatment.â JAMA, June 4, 2017.
Basch, E, et al. âSymptom Monitoring With Patient-Reported Outcomes During Routine Cancer Treatment: A Randomized Controlled Trial.â
Journal of Clinical Oncology 34, no. 6 (February 20, 2016):
17. PC in Stem Cell Transplant
El-Jawahri, et al JAMA 2016
ďPatients undergoing hematopoietic stem cell
transplantation had standard inpatient PC consultation
during transplant hospitalization at Duke
ďPC patients received 2+ idt visits per week
ď Patients receiving PC had significant difference in QOL,
depression, anxiety, symptom burden at 2 weeks.
ď QOL improvement durable at 3 months
ď Caregivers had significant difference in depression
El-Jawahri, Areej, Thomas LeBlanc, Harry VanDusen, Lara Traeger, Joseph A. Greer, William F. Pirl, and
others, âEffect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell
Transplantation: A Randomized Clinical Trialâ, JAMA, 316 (2016), 2094â2103
<https://doi.org/10.1001/jama.2016.16786>
18. âWhatâs in the serum?â
ďInterdisciplinary consultation team
ďInpatient and outpatient presence, possibly telephonic
ďSpecialty trained clinicians in addition to primary
palliative care
ď3-4 months minimum involvement
ďPrognostic awareness- understanding of illness,
prognosis and potential benefits of treatment
ďComprehensive & ongoing assessment of distress
ďQOL, Physical, psychological, spiritual & social
ďIntegration with oncologic care
19. ASCO Clinical Practice Guideline
Update
ďFerrell, et al J of Clinical Oncology October, 2016
ďAll patients with advanced cancer should receive
concurrent, dedicated palliative care services
ď Essentials: relationship building, distress management,
prognostic awareness, goals, coping, decision making,
collaboration
ďPC available early (within 8 weeks of dx) inpt/outpt
ďPalliative Care should include interdisciplinary team
ďCaregivers should also be considered for support
Ferrell, Betty R., Jennifer S. Temel, Sarah Temin, Erin R. Alesi, Tracy A. Balboni, Ethan M. Basch, and others, âIntegration of Palliative Care Into Standard
Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Updateâ, Journal of Clinical Oncology, 2016, JCO.2016.70.1474
<https://doi.org/10.1200/JCO.2016.70.1474>
20. PA Plan for Oncology Palliative Care
ďNo certifying agency governing palliative care
ďQuality measures coming from other specialties
ďTherefore in 2014-2015,
ďSurvivorship and Palliative Care Stakeholder
Leadership Team (SLT) of the Pennsylvania (PA)
Comprehensive Cancer Control Coalition, a working
committee of the Pennsylvania Cancer Advisory Board
(CAB), prioritized Objective 3.3 of the PA
Comprehensive Cancer Control Plan (2013-2018)
âFacilitate collaboration to increase attention to
appropriate use of palliative care and improve quality of
21. PA Standard for Essential
Elements and Accessibility of
Palliative Care Services
Patients with cancer and their designated family
members or caregivers should have access to palliative
care across clinical settings including inpatient,
outpatient, long term care facilities and home. Services
may be provided within the cancer organization or
through community partnerships to provide all of the
following:
22. PA Standard for Essential Elements and
Accessibility of Palliative Care Services
ďInterdisciplinary team collaborates on plan of care
ďAttention to patient goals for treatment and communication preferences
ďEvidence based screening & management of symptoms & distress
ďSpecialty Level palliative care by board certified clinician
ďCare of patient at the End of life and post-death care
ďGrief and Bereavement support
ďQuality improvement plan
ďStaff support to prevent compassion fatigue
ďEducation for clinicians & trainees
ďPalliative care representation in leadership
23. Palliative Care in Practice
âWhen youâve seen one palliative care programâŚâ
ďCertification for palliative care programs
ďJCAHO inpatient certification
ďNo outpatient/home based certification:
standards/recommendations only
ďHospital, Clinic Based
ďHome Health/Hospice based
ďHealth system versus community partnerships
ďWe must hold ourselves accountable & ensure quality
care is delivered- avoid undermining
26. Palliative Related Quality Measures
Oncology Care Model
ďCompletion of Oncology (Patient centered)Care plan
ďHospitalizations, ED Visits, Hospice > 3 days (median 18!)
ďPain, depression, patient experience
American Society of Clinical Oncology (ASCO) Quality Oncology
Practice Initiative (QOPI) measures
ďEvaluation of pain by the 2nd
visit Emotional well-being
assessment and management Dyspnea assessment and
management
ďDocumentation of palliative versus curative, intent discussion
with patient documented
We need to demonstrate our quality, not just decreased cost!
27. Next frontiers: Research & Care
ďPC for non-advanced cancers: Data emerging- not yet
strong enough to support guidelines but Ferrell et all
found improved QOL in early stage lung cancer1
ďEvaluating and considering âQuality of Deathâ2:
QOD is
not improved, and can be harmed, by chemotherapy use
near death, even in patients with good performance
status.
ďCaregiver needs: well documented distress, increased
mortality but how to intervene?3
1. Ferrell, et al âInterdisciplinary Palliative Care for Patients With Lung Cancerâ, JPSM, 50 (2015), 758â67
2. Prigerson et al, âCHemotherapy Use, Performance Status, and Quality of Life at the End of Lifeâ, JAMA Oncology, 2015
3. McDonald, et al âImpact of Early Palliative Care on Caregivers of Patients with Advanced Cancer: Cluster Randomised
Trialâ, Annals of Oncology 2016
28. Where do we start?
ďNeeds assessment: Clinicians, Patients, Health
systems, Insurers, quality measures
ďPartnerships: Champions in system, community
organizations
ďEducation& Advocacy: ASCO Pall Onc, AAHPM,
PHPCN, Pediatric Palliative Care Coalition
ďProgram Development
ďCenter to Advance Palliative Care (CAPC)
ďNational Quality Forum
29. Take-aways:
PC is meant to supplement, not detract, from oncology care
with evidence-based improvement in symptoms, quality,
satisfaction and possibly mortality with decreased cost soâŚ
ďDonât equate PC with hospice
ďDo recognize the need for disease specific palliative
education and consult the literature (or at least look at Fast
Facts!)
ďDo offer specialty palliative care consultation to all patients
with advanced cancer, within 3 months of diagnosis
ďDo discuss prognosis and expected outcomes, to facilitate
shared decision making, improve appropriate care choices
ďDo assess whole-person distress early and regularly
ďConsider assessing and supporting caregiver needs
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Editor's Notes
Use clinical examples!
Talk about why you went into it â Mr. Santana
Talk about what you do every day.