Posts tagged Annual Assembly

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

Peds SIG Offers New Avenues for Involvement in the Field

Although it was painful to get up so early on the final day of the AAHPM Assembly in Vancouver, it was completely worthwhile to attend the meeting of the Pediatrics Special Interest Group (SIG). Over the years that I’ve attended this meeting, it’s been amazing to watch the evolution of interest and attendance in our SIG, and the parallel explosion of pediatric education, research and advocacy opportunities.

In 2007, our statewide pediatric palliative care (PPC) network OPPEN (Ohio Pediatric Palliative and End-of-life care Network) organized a national conference as a follow-up to the National Hospice and Palliative Care Organization’s (NHPCO) pediatric conference in Dearborn, Michigan in 2004. These efforts were organized precisely because there was no place for PPC providers to go to find educational and research information and to network with colleagues; most national conferences had only occasional, if any, pediatric content. Fortunately, that has certainly changed!

For the past few years, the AAHPM has offered greatly increased pediatric content at the Assembly, with pediatric sessions in almost every concurrent slot, as well as large numbers of pediatric paper presentations (which are often award winners). Pediatric representation exists throughout the organization, from workgroups and committees through the Board of Directors.

Similarly, NHPCO has been offering a pediatric track at its Clinical Team Conference for several years now, and its advisory group ChiPPS (Children’s Project on Palliative and Hospice Services) has expanded, undergone strategic planning, and taken on a leadership role in equipping hospice and palliative care organizations to care for children and in working closely with NHPCO in its advocacy and policy activities (www.nhpco.org/pediatrics).

The American Academy of Pediatrics (AAP) has also jumped on the PPC bandwagon, with the establishment of the Section on Hospice and Palliative Medicine. This group is focusing primarily on policy and educational activities, including opportunities for scholarly activity through the AAP’s main meeting, the National Conference Exhibition. The Section maintains 2 listservs that boast healthy discussion about many aspects of our field, 1 for members and 1 for any interested parties; Affiliate Membership is possible for non-physicians as well (www.aap.org; check out the web page soon for a more expanded discussion of each of these national opportunities for PPC involvement and commitment).

The Center to Advance Palliative Care has recently increased its pediatric focus too. Last fall, the annual conference included a pediatric track for the first time, and that will continue this year. Palliative Care Leadership Center tools and training for programs interested in starting or growing a PPC or hospice program have been available through a number of different sites for years; in 2008, 2 pediatric-specific sites were added (Akron Children’s Hospital and Children’s Hospitals and Clinics of Minneapolis) and a new pediatric curriculum was developed (www.capc.org).

And there are other groups involved with PPC as well. A few more highlights include:

  • PEPPERCORN, the Pediatric Palliative Care Research Network, a dedicated group of researchers from a number of sites across North America who are working individually and collaboratively to advance the science of PPC
  • The Hospice and Palliative Nurses Association (www.hpna.org), which has successfully developed a pediatric nursing certification examination in hospice and palliative care, and is also developing accompanying educational material
  • The National Networks for Pediatric Palliative Care (www.network4pedspallcare.org), a grassroots effort focused on developing a web-based clearinghouse of programs and information for families and providers.
  • The Pediatric Hospice and Palliative Medicine Competencies Project, a group of PPC leaders who have been working with the original HPM competencies document and authors to create a companion resource for pediatrics; importantly, the AAHPM’s Board of Directors approved support for this project at this year’s board meeting.

During this time, the Academy’s SIG has continued to meet and grow. In the last few years, we’ve become more organized, along with all SIGs in the Academy which are receiving more support through the new and expanded Communities model. We’ve developed an elections process, allowing a rotation of leadership and the opportunity for younger or newer folks in the field to become involved. This year’s Assembly featured a Pediatric SIG-sponsored session which was very well received. And there were a tremendous number of great suggestions for next year’s Assembly that were generated at the SIG meeting. Our next big push will be for a pediatric plenary!

In short, it’s a great time to be in pediatric hospice and palliative care. Seeing colleagues, learning about many new avenues to become involved in the field, talking about challenging and uplifting situations, sharing wisdom and lessons learned, and literally catching the contagious excitement among us were just a few of the reasons to get out of bed on Saturday morning for the SIG meeting. Hope to see you there next year in Denver!

Gratitude: Service of Rememberance and Celebration

What a wonderful way to celebrate and remember all of us who care for our patients. The theme brought us back to Mother Earth as we are in the beautiful setting of Vancouver where we all are here to support each other. The symbol of the tree was used in several ways from the tree created during the conference by those attending and remembering those dear to them and also on the front of the handout with the Arbutus Tree (Madrone) which holds the tile of most sacred to inhabitants of this coastal region. I think the tree even though it looks like they stand alone are actually connected in many ways. And so are we.

I especially enjoyed the celebration because of it’s emphasis on gratitude. I think in the hard days we face and the many challenges, many of them discussed during the conference, that we remember to return to ourselves and be grateful. To have gratitude as we complete our day for the work we are called to do. Grateful for the sun that warms us, the ground we walk on and the air we breath. To also cherish our heritage personally and united as presented by Gabe George and Carleen Thomas from the Tsleil-Waututh Nation meaning “People of the Inlet”.

Gabe shared with us the loss of his brother from HIV and how he learned that healing is best done through song. Carleen and Gabe shared many songs with us and the healing in the room could be felt.

Patrick Clary also shared with us his healing journey which has taken many years and started in his youth with his magpie.

In a unique experience, often we share our monetary offerings, but what we received was a gift made by Kelly Two Wolves (she was introduced to us in the earlier plenary session). The beads represented the North (Red), West (Black), South (White) and East (Yellow) and the representation of the colors of the human race. The beads were presented in a bracelet, circular, joined and never ending showing we are ALL connected (related). This reminded me of another practice I learned this year, The Medicine Wheel.

In closing we joined in the Aztec Prayer of Community.

Only for so short a while, O God,

You have loaned us to each other.

Because we take form

In your act of drawing us.

And we take life

In your painting us.

And we breathe

In your singing us.

But only for so short a while

Have you loaned us to each other.

Thank you for this wonderful experience.

Palliative Care in the Age of Healthcare Reform: The Impact on Your Practice (403)

Diane Meier’s talk this morning was less a presentation than a call for action to the palliative care field. Dr. Meier spent a year working on capital hill and has continued to advocate for palliative care on a local and national level.

She began with a review of the Affordable Care Act and the challenges faced in our country given the current unsustainable spending on healthcare. More and more people are looking to the value equation: Value=Quality/Cost. The United States struggles to increase value and has been unable to accurately measure and increase quality, costs have continued to rise. As we debate how to cut costs it is critical that palliative care not be left out of the discussion.

Currently, most of the talk around bending the cost curve has been related to changing payment structures including the formation of Accountable Care Organizations (ACOs). High quality, well integrated palliative care is a critical piece the health care continuum, and we should be advocating that it is included in any discussion of ACOs.

Unfortunately, there are very few voices from the palliative care community “at the table” in Washington and so our concerns are often not addressed. Only a tiny portion of NIH funding (0.01%) is devoted to research in the field of palliative care which only leads to further misunderstanding of our views and mission.

So how can we make a difference? How can we make sure the palliative care is included in health care reform efforts going forward? Dr. Meier outlined several steps that we can take as a profession and as individuals.

  • Language is important. We must be consistent in how we talk about what we do. Her suggestion: “Palliative care is about matching treatment to patient goals.” What do you think?
  • Submit your organizations data to CAPC’s registry so that quality is measured and improved.
  • email/call/write a letter to your congressperson. AAHPM has made it easy!
  • Mark time off in your calendar to meet with your congressional representatives to discuss and lobby for palliative care.

Our elected officials want to hear from us and they take our views very seriously. As an movement we need to start speaking up or health care reform is going to pass us by.