Posts tagged #aahpm #hpm

Chemo in the last 2 weeks of life

Chemotherapy is a two-edged sword. As an oncology trainee I’ve seen a few patients die solely because of it. And yet aggressive treatment is sometimes necessary to save a life; in the right settings it often succeeds. Patients with Hodgkins’ disease, testicular cancer, acute leukemias, and early stage colon, lung, or breast cancers, among others, are often cured because of chemotherapy and other aggressive treatments. Like any useful tool though, it must be properly applied in order to be effective and avoid harm. You wouldn’t use a screwdriver to drive a nail; similarly, chemotherapy shouldn’t be given to all patients in all situations, nor should it be a substitute for good discussions about goals of care and the likelihood of deriving benefit.

Yesterday’s cancer SIG presentation cut to the core of many issues that create tension between oncologists and palliative care clinicians. Most of us have probably seen difficult situations involving chemotherapy; it can be very upsetting! We tend to point the finger at oncologists when things go wrong, but we must recognize their unique perspective. To paraphrase one of today’s presenters, “Sometimes I can give a patient 5 different rounds of chemotherapy over 7 years and see them respond well each time.” In other words, chemo often really helps patients, even when its intent is palliative. I promise, we’re not monsters….oncologists are people too! :)

Data support the use of chemotherapy in a number of advanced disease settings, even many solid tumors. Yes, chemotherapy can and should be part of good palliation in many settings. There are significant symptom benefits, QOL improvements, and survival benefits to be had in cases of lung, breast, colon, and prostate cancer; many other solid tumors respond to chemotherapy as well. Of course, the devil is in the details. An emerging quality indicator in oncology practice is the proportion of patients receiving chemotherapy in the last 2 weeks of life. Too many patients are receiving chemo just before death.

Here’s the conundrum: we know chemotherapy can be beneficial, but only in certain settings. Unfortunately we’re not very good at predicting how well a particular patient will tolerate treatment, nor how well their tumor(s) will respond. How should we proceed?

The SIG speakers recommend following a framework: First, look to published guidelines like those from the NCCN, which tell us when chemotherapy is no longer recommended (link). If treatment is pursued, it must be done with full informed consent regarding its palliative intent. Treatment must be viewed as a time-limited trial, with specific criteria for measuring response and planned discontinuation if none is seen. Transitions to hospice should be discussed early, at the first signs of decline in function. And the palliative care team should be involved! As Dr. Smith pointed out, recent data on early palliative care in advanced lung cancer shows a resultant reduction in chemotherapy usage in the last 60 days of life. We still don’t really know how this works, but it works, and it doesn’t impair survival.

Going forward, palliative care will become more integrated into comprehensive cancer care, as per recent recommendations (link). This requires palliative care clinicians to better understand the role of chemotherapy as part of good palliative care for many cancer patients. Let’s be constructive, and increasingly work side-by-side with our oncology colleagues in caring for patients with incurable cancer. Hug an oncologist today! :)

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

Concurrent Session – Delirium

Trust psychiatrists to give an afternoon session that makes you completely forget about that nap you were craving! “Delirium: A Study of Difficult Cases” consisted of 3 vignettes about various forms of delirium, complete with very realistic role playing and chock full of wisdom from palliative care psychiatrists.

First there was a case of reversible hyperactive delirium. We were reminded that just about anything could be the culprit behind it, including common HPM meds like opioids and benzodiazepines, minor infections, metabolic derangements, and overstimulating environments.

How to treat the agitation in reversible delirium? First try to reduce stimulation and create a soothing environment. Can you eliminate any unnecessary meds? AVOID benzos! Use 1st generation antipsychotics such as haloperidol or chlorpromazine (more sedating than haloperidol), and dose the way you would dose pain medications.

What about irreversible delirium? This is the kind that occurs during the dying process, so a good clue that it’s not reversible is that there will be physical signs of dying. In this case, you can use antipsychotics, but you could also use benzos like lorazepam or midazolam. Remember that the goal is to reduce suffering by reducing the agitation of delirium — this is NOT palliative sedation, this is medical managment of a medical symptom.

Sometime benzos won’t be effective, and in those rare cases you could try propofol or phenobarbital. The key point is to treat agitation like a breakthrough symptom.

The final vignette illustrated a case of mixed delirium in pediatric palliative care (complete with role playing where the parent was as much the patient as the kid). Yes, delirium happens in kids too! This is a sneakier form of delirium (and can happen in adults too) that presents with waxing/waning symptoms. The gist is that you treat kids the same as adults (though with lower doses) — haloperidol and risperdal (both antipsychotics) are effective and safe in kids and infants.

I left with the understanding that delirium is a form of suffering, and as patients who come out of it later say, is a terrifying and disorienting experience. Treat it proactively and don’t hesitate to consult psychiatry for tough cases!

Erin Zahradnik, MD, PGY-3 Yale University Dept of Psychiatry

“Bending the Cost Curve:” reflections on this morning’s plenary session

America, your bluff has been called…the verdict is in, and the old adage remains true: you cannot have your cake and eat it too (shocking news, I know). Clichéd as it may sound, that message rang true this morning as the annual assembly opened in a blaze of introspection and criticism of the status quo. The target? Rising healthcare costs. Even current levels of U.S. healthcare spending are unsustainable, yet we continue on a path of rising costs without adequate thought regarding the value of care provided.

The panel discussion featured Thomas Smith, Brad Stuart, and Rebecca Kirch, each presenting perspectives on the problem and fielding questions. Smith hit the nail on the head, pointing out that “value is missing, care is not optimal, and costs are rising unsustainably.” He highlighted some staggering statistics from a sample of cancer patients at a major academic medical center (Dy, et al, 2011). Roughly 1/3rd received chemotherapy within 2 weeks of death, ~25% ended up on a ventilator, less than 1/4th were discharged to hospice care, and ~1/3rd died in the hospital. Quite a sad state of affairs! Yet insurance premiums are rising quickly, having doubled between 2000 and 2010; herein lies the “missing value.” What are we buying with all this money spent? What’s a society to do?

At this point someone usually drops the “R-bomb,” which can curtail any meaningful debate. Imposing limits on healthcare is such a charged and seemingly un-American idea. Must rationing be the only solution though? Per Brad Stuart, the answer to this question is a resounding “no!” Stuart described a program called AIM (Advanced Illness Management), which effectively turns this debate on its head. Rather than focusing on imposing limits, AIM emphasizes the importance of eliciting and defining patient preferences early (and often), and facilitates doing this in the community rather than just the hospital. AIM data show how this approach can yield improved outcomes, higher quality of care, and even decreased costs!

This sounds like what many of us in palliative care already think we do; we’re communicators, goals elicitors, and compassionate caregivers. But we are handcuffed by a system that often views us as the alternative to aggressive treatments, especially in cancer care, and we’re often involved too late in the process. Thankfully, this too is changing. A recent guideline from the American Society of Clinical Oncology recommends early palliative care for all patients with advanced cancers (link). Palliative care is increasingly viewed as a part of the solution and a part of quality cancer care, rather than an adversary.

In this climate, 2012 is a time of enormous excitement for our field! How we brand and conduct ourselves though, is crucial. We must be partners in cancer care, not antagonists. As Kirch taught us in reviewing the CAPC report, how we talk about palliative care truly matters; if we do it “correctly,” patients are overwhelmingly interested in what we do, and would want it for their loved ones (link).

As a trainee in both oncology and palliative medicine, I cannot imagine a more exciting time to be working at the intersection of these fields. Let’s continue to work together to blaze a trail towards increasing quality of life and quality of cancer care. In line with the AIM program, and those like it, let’s be champions of patient choice, rather than reapers of grim. Palliate early, and often!

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

AAHPM pre-conference workshop: Junior faculty bootcamp

“Early Career Hospice and Palliative Medicine faculty Development Bootcamp”: Drs Bernacki, Carey, Sanchez-Reilly, Periyakoil, Kapo, DeLima Thomas, Morrison, and Bunch O’Neill

I was a little apprehensive about this workshop, since I’m still a fellow and not even junior faculty yet. I will be taking a faculty position when I finish my fellowship, so I figured that whatever I learn will still be applicable four months from now. I think many trainees wonder what it means to be an attending, and especially about the mysterious “non-clinical time” (which residents and fellows get just enough of to know that we probably want more of it!). I do know enough to know that it will be different than anything I’ve done so far, in terms of work-flow, responsibility, and expectations. To add to my uncertainty, I am joining our section as part of a significant expansion which will mean changes in how the entire section functions. I was hoping for some strategies to manage what feels at times to be a monumental task, and I was not disappointed.

We started by creating mission statements for ourselves: short, using active language, and focused on what we want to achieve and why. My mission statement: To improve medical care by expanding palliative care education at all levels. It was really inspiring to see how big we are dreaming! Other topics covered included time management (oh Covey square, where have you been all my life?) and conflict resolution (both in the context of patient interactions and with professional colleagues).

When we talk about interactions with patients and families, we often talk about being intentional in our approach, to be mindful and centered in order to function most effectively. What I am taking home from this workshop is a greater sense of intention as I start my career, with my specific goals in mind and a much greater awareness of my own strengths as a palliator and as a faculty member. I was also really struck by the obvious camaraderie between our presenters, and the strength they derived from having a peer mentoring group. At our table we had a wonderful group of people and it was both somewhat therapeutic and also really fun to share stories about challenges in each of our lives. It was really striking how the same themes kept coming up over and over again across the whole group. Take home message: it can be hard to be a junior faculty member, and what you’re going through is normal!

I walked out of the workshop focused on my goals, inspired to implement some of the tools we learned, and feeling more confident in my ability to shape my career to match my vision. I am really looking forward to the rest of the conference, meeting more new faces and getting more inspiration for what I already consider the greatest job there is.

Meredith MacMartin, MD, HPM Fellow at Dartmouth-Hitchcock Medical Center

The Devil Is in the Denominator

To improve quality, whom we measure is as important as what.

by Joe Rotella, MD, MBA, FAAHPM

The growing awareness in America that our healthcare system is unaffordable and fails to deliver consistent quality has led us to healthcare reform, mandatory quality reporting, pay-for-performance, and Accountable Care Organizations (ACOs). We need good measures of quality healthcare so we can direct our limited resources where they provide the most value. We would do well to pay particular attention to the quality of care near the end of life. As Ellen Goodman noted in her recent Harvard Business Review article “Die the Way You Want To”, 25% of Medicare expenditures are incurred by the 5% who are in their last year of life. Surely we can deliver more value by increasing quality of life and decreasing futile medical interventions for these patients.

It makes sense that we should measure quality in order to improve it, but figuring out exactly how can be a real devil. We often focus on what we should measure—the numerator, but whom—the denominator—is just as important. Working on the AAHPM Quality and Practice Standards Task Force this past year has been an eye-opening experience for me. Wading through ponderous technical documents describing a host of proposed national quality measures, I was struck with how hard it is to design a really good one. The National Quality Forum (NQF) recently recommended a set of quality measures for hospice and palliative care. The NQF only recommends measures with well-defined methodologies validated for the specific populations under consideration. Many employ a narrow denominator, e.g. hospice patients rather than dying patients. It’s a good start, but I hope policymakers and payers will be careful in how they incorporate them into mandatory quality reporting systems. Measuring only hospice patients in order to improve the quality of end-of-life care is like searching for a lost dollar bill only where the light is good. The real payoff may be lurking in that dark corner.

For example, the best set of quality measures we have for end-of-life care so far, the Family Evaluation of Hospice Care (FEHC), has only been validated for hospice patients. When we apply the FEHC to hospices, we can compare the quality of Hospice A with that of Hospice B. That might be good enough if most dying patients received hospice care, but the National Hospice and Palliative Care Organization reports in its 2011 Facts and Figures that only 42% of those who died in 2010 were enrolled in hospice. So what about the quality of end-of-life care for the majority of patients who die in hospitals, skilled nursing facilities and homes without the benefit of hospice care? How can we measure that?

Current and proposed mandatory quality reporting programs perpetuate the silos in our healthcare delivery system. Since hospitals are designed for treating acute, potentially-reversible problems, they report post-discharge, patient-rated satisfaction surveys that totally miss the experience of the many patients who die during their stay. Likewise, we see skilled nursing facilities as places for rehabilitation, so we require a Minimum Data Set that focuses on restoration of function, even though many patients languish and die there. Since hospice is the place for dying, that’s where we’ll mandate reporting of end-of-life quality measures, but that’s not going to improve the quality of dying where most of it happens.

The Medicare final rule creating ACOs requires them to report on 33 quality measures linked to how much they can share in any savings. Despite the striking disproportion of Medicare dollars spent in the last year of life, none of these measures has anything to do with comfortable dying or the appropriate utilization of hospice or palliative care. In the original 127-page proposed ACO rule, the word “hospice” appeared once and “palliative” not at all. Comments from the AAHPM and others must have been heard, because the terms appear about a dozen times in the final rule. It’s a step in the right direction, but we have a long way to go. We need researchers to develop and validate quality of life and quality of dying measures for all relevant care settings. Once available, we should push for their inclusion in all mandatory quality reporting and pay-for-performance systems. We’ll never get the maximum value for the Medicare dollar without it.

President Crossno’s Letter to American Medical News

Letter to American Medical News

January 6, 2012

Re: Handful of States Promise Physicians Online Access to Advance Directives, posted January 3, 2012 on amednews.com http://bit.ly/vFKMvx

When very sick patients are unable to express their wishes toward the end of life, nothing is more heartbreaking for doctors and loved ones than not knowing what those wishes are. It’s up to grieving and frightened family members to try to recall a past conversation, or remember whether there’s an advance directive, and if so, how to put their hands on it. Online registry programs for advance directives that give doctors access to this information would help ensure that we meet our patients’ wishes and that we don’t leave family members always questioning the decisions they were forced to make.

Patients need to hear from their doctors the importance of advance directives. They need to know that an advance directive can be changed, and that it can direct doctors to stop aggressive life-saving treatments, or continue them. Most important, an advance directive needs to be readily accessible when you need it. The American Academy of Hospice and Palliative Medicine has information on advance directives at www.aahpm.org and www.PalliativeDoctors.org

Ronald J. Crossno, MD CMD FAAFP FAAHPM

President, American Academy of Hospice and Palliative Medicine

What Is Palliative Care?

by Ruth Mugalian, Public Communications Inc.

Read the full article about defining palliative care in the Winter issue of The Quarterly.

When I talk about my work with hospice and palliative medicine specialists and why I enjoy it, I usually say something like this: “They’re doctors who take care of very sick patients. They relieve their symptoms and make them feel better.” It should be a communications professional’s dream. It’s simple, understandable and positive. There’s no esoteric medical jargon or complex technical language to translate into layman’s terms.

And yet, that simple, positive description doesn’t quite capture it.

Describing what hospice and palliative medicine specialists do is an evolving challenge, as evidenced by the many different ways the doctors explain their work. Unlike many other medical specialties, there’s no simple one- or two-word description, like “heart surgeon” or “cancer specialist.” “They relieve symptoms” is far too narrow, but also too broad. Don’t most doctors relieve symptoms? And, what about all the other care they provide: the help with decision making and navigating the system, the coordination of care, the support for families?

Just summarizing the breadth of care is challenging enough, but of course, there’s another challenge. The heart surgeon fixes the heart. The cancer specialist attacks the cancer. HPM doctors don’t cure. They provide the care that helps the surgeon and the oncologist cure, and that helps the patient endure the cure.

And sometimes there is no cure. That’s when the HPM’s role takes on special meaning and ironically and frustratingly gets twisted into something negative: they withhold care, give up on the patient, hasten death. Of course, the opposite is true. They stay on the job when others have no more to offer. They continue, or begin, providing care when others have stopped. They’re passionate about controlling pain. Snappy phrases are tempting: “They don’t cure, they care.” “They never stop caring,” “Helping you endure, with or without a cure.” They’re simple, understandable and positive, and they don’t quite capture it.

New Drugs and Drug News – The 411 and implications for palliative care (334)

This session could also be known as: a whirlwind journey through 2010 pharmacology with Mary Lynn McPherson, Pharm.D., BCPS, CPE from the University of MD. She is a very entertaining and engaging speaker, also very quick! She reviewed the FDA decision to remove propoxyphene from the market, which has been highlighted in other blogs as well. She discussed the FDA concerns and restrictions regarding acetominophen in common opiod formulations. In addition, I didn’t know there was an official definition of opiod tolerance – any one of the below:

  • 60 mg oral morphine per day
  • 25 mcg TDF every three days
  • 30 mg oral oxycodone per day
  • 8 mg oral hydromorphone per day
  • 25 mg oral oxymorphone per day

Several highlights to remember:

  • Many new and very expensive drugs on the market taking advantage of alternative delivery systems
  • Nuedexta (dextromethorphan/Quinidine) for uncontrolled laughing/crying in neurological diseases. Helpful but over $600/month
  • Abstral (SL Fentanyl) available. Extensive REMS (Risk Evaluation and Mitigation Strategies – FDA) which will include special certification for providers as well as pharmacies.
  • Exalgo – a once daily hydromorphone formulation
  • BuTrans – transdermal buprenorphine which can be worn for 7 days for pain relief
  • OxyContin reformulation – designed to prevent abuse, many patients feel it isn’t as effective.
  • Duloxetine (Cymbalta) – indication for chronic musculoskeletal pain (low back pain, etc)
  • Acetaminophen IV (Ofirmev) available – long awaited by many (including me!). Will be over $10 per dose, compared to pennies for other routes of administration. Will still be huge blockbuster!
  • Cryostat – a very effective cold pack for hemorrhoid relief

Overall, LOTS of information in a great presentation. I was only sorry it was at the end of the day (I feel much sharper earlier in the day!).

Would be curious if anyone else picked up other tips that might be helpful – please share in comments.

Hospice medical director course

half way through the Pre-con. Some good nuggets for experienced directors, but most will know most. Q+A great