4/20/2018 Complex Illness Support Objectives Alongside Standard Oncology • Discuss Complex Illness Support Care for Patients with • Review rationale for early Palliative Care Incurable Cancer • Summarize Outpatient Experience • Determine lessons learned Kim Bland, DNP, APRN-NP, FNP, AOCN Trajectories of Function and Well-Being over Time in Eventually Fatal Chronic Illnesses Disease Trajectory High Initial Therapy (curative) Disease-free Relapse Progression Cancer Increasing Symptoms Organ System Failure Salvage Therapy Palliative Care Function Progression-free Deterioration Dementia- Frailty Low Death Comfort Care (Hospice) Time Death Background Early, Integrated Palliative Care in Patients Outpatient Consultation Service with Metastatic Lung Cancer Justification: most patients spend most of Palliative Care Model Early palliative Palliative care provided by physicians their time outside of hospitals care integrated and nurse practitioners 150 patients with standard oncology care with newly Visits occurred in the Cancer Center diagnosed (medical oncology, radiation metastatic Standard oncology or chemotherapy • Opportunity NSCLC oncology care visits). – Improved quality patient care Oncology and palliative care visits – Potentially decreased acute care stays and mortality were done in tandem or simultaneously. – Increased efficiency in health care systems and accountable care organizations Visits were not scripted or prescribed. If patients were admitted to the hospital, they were followed by Temel et al., NEJM (2010), 363 the palliative care team 1 4/20/2018 Results Literature Review: Early Palliative Care Newly diagnosed metastatic NSCLC patients enrolled between 2006-2009 • Incorporation of palliative care ALONGSIDE standard oncological care for NSCLC patients • Reported better QOL and less depression - Longer Median survival • Chose less aggressive care at EOL - Increased Quality of life • “Survival prolonged by 2 months” - Improved accuracy of illness perception (11.6 versus 8.9 months) - Less aggressive treatments at end of life • “Clinically meaningful improvements in quality of life and mood” - Fewer depressive symptoms Temel et al., NEJM (2010), 363. Early Palliative Care Intervention Project Summary: More accurate perception of prognosis (“incurable”) October 31, 2016 through March 16, 2017 13 referring physicians: Less likely to receive aggressive treatments near 1 PCP and 12 Oncologists the end of life Referral Guidelines How Should we Design Interventions to Improve The Delivery of Cancer Care? • Incurable cancer • Significant symptom burden related to cancer or treatment • Poor performance status (PPS 50 or less) 1. Focus on patients in the ambulatory care setting • Psychosocial situation interfering with receipt of treatment 2. Allow patients to have cancer care and Palliative Care • Multiple admissions / ER visits • Help with complex decision making / advance care planning / goals 3. Provide early and continued relief from physical and • Conflicting goals between patient and family psychological symptoms • Existential distress may benefit from support 4. Enhance communication between patients and • Patient or family request support and consultation clinicians AND patients and their families to improve • Seen by inpatient palliative care and needing follow up decision-making • Concerns about caregivers / support systems • Assistance with complex illness management 5. Provide the most appropriate care at end of life • Discussion and referral for hospice care 2 4/20/2018 ACCESS Complex Illness Support Embedded Clinic Model • Realistic patient and family-centered care goals: – Re-evaluate throughout the duration of illness • Collaborative relationship between a host clinic – Empower patients and families about healthcare choices and palliative care staff – Facilitate referrals to appropriate community programs • All costs of the clinic operations are born by the – Encourage Advanced care planning host clinic • Expert symptom and comfort management: • Patients referred predominately from the host clinic – Whether pursuing aggressive life prolonging care or comfort measures only • Defined clinical pathways or protocols may exist – Independent of prognosis defining patient flow between the host and • Focus on patients with progressive life limiting illness with palliative care staff prognosis of one year or less Actual Referral Diagnosis Number of patients seen: 18 Metastatic Breast • Number of patient visits: 22 (13 new and 9 follow up) Metastatic Pancreatic – Race: 16 Caucasian / 2 Hispanic • Stage I NSCLC (Poor PS) – Gender: 2 Male / 16 female – Average age: 71.7 years old Metastatic pleural Mesothelioma Metastatic pelvic adenocarcinoma, unknown primary • Treatment status: Myelodysplastic syndrome – Receiving cancer treatment: 14 • Synchronous Stage Lung cancer and metastatic melanoma – Stopped or refused treatment: 3 Metastatic lung cancer – Had not yet started treatment: 1 Stage Ib Lung cancer, new epiglottic mass probably cancer Stage IIIA lung cancer; difficult surgery decision • Enrolled to hospice: # 10 Stage IV endometrial cancer – One remained alive • Stage IIIB cervical cancer – One patient refused hospice, expired • Dementia, prostate cancer Acute Myelogenous Leukemia, history of Breast and Colon Cancer • Mortality: 10 of 18 expired: 56% **Indicates patient expired 3 4/20/2018 • Emergency department use and disposition: 2 patients – Weakness and pain – discharged home – Cough, hallucinations, vomiting: was on hospice, returned to hospice • Hospitalizations and length of stay: 8 patients – Cholecystectomy – outpatient surgery: 1 day – Syncope – observation patient : 3 days – Pulmonary Emboli: 3 days – Fatigue, nausea: 9 days – New atrial fibrillation, Cardizem drip: 3 days – Malignant pleural effusion, tapped: 10 days – Weakness: 11 days; discharged to Skilled nursing facility – Anemia, dyspnea: 10 days; discharged to home hospice – Sepsis: 13 days; discharged to hospice house • ICU use: 1 patient – Sepsis, intubated. Patient had been seen inpatient and outpatient prior, very resistant to discussions on code status, advance directives, and goals of care. Treatment at end-of-life • Average Number of Days from last chemo : 43.6 days • Average Number of Days from last chemo or Radiation: 47.16 days • Average Hospice days: 20.2 days – One patient refused hospice = no hospice days Patient satisfaction with Complex Illness Support Comparison to benchmarks CIS Literature All surveyed strongly agreed: Chemo last 14 days 6% 5.6-20% √ The CIS team was respectful and professional Chemo last 30 days 12% 9 - 50% √ I was able to talk about my goals and preferences for future care ED visit 11% 4.57 -47.8% √ The team helped me to feel more comfortable Hospitalization 44% 4 - 92% (Emotionally and with symptom management) ICU use 6% 5.86-15.4% √ The CIS team helped to coordinate my care Hospice admission 94% 47- 59.9% √ I am satisfied with the CIS team Hospice days 20.2 4 -19.7 Acute care death 0 28.6% 4 4/20/2018 References: • Temel, J., Greer, J., Muzikansky, A., Gallagher, E., Admane, S., Jackson, V., . & Reflections Lynch, T. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. The New England Journal of Medicine, 363(8); 733-742. • ‘No show’ patients are reflective of misperceptions about palliative care, • Stuver, S., McNiff, K., Fraile, B., Odejide, O., Abel, G., Dodek, A., & Jacobson, J. how complexly ill patients are, and late referrals. (2016). Novel data sharing between a comprehensive cancer center and a private payer to better understand care at the End of Life. Journal of Pain and Symptom Management, 52(2); 161-169. • Patients and providers are accepting of and asking for outpatient Complex • Von Roenn, J. & Temel, J. (2011). The integration of palliative care and oncology: Illness Support The evidence. Oncology, 25(13); 1258-1266. • Greer, J., Pirl, W., Jackson, V., Muzikansky, A., Lennes, I., Heist, R., Gallagher, E., & • In this five month project, 56% of patients referred to Complex Illness Temel, J. (2012). Effect of early palliative care on chemotherapy use and end-of-life support died. This affirms the rationale and need for early supportive care care in patients with metastatic non-small-cell lung cancer. Journal of Clinical Oncology, 30(4); 394-400. intervention. • Abramowski, M. & Astarita, P. (2017). Building a palliative care program from the inside out. Oncology Issues, Jan-Febr; 37-46. • Expanding services would enhance patient care and satisfaction, as well as • Murillo, J. & Koeller, J. (2006). Chemotherapy given near the end of life by provide benefit to patients, families, and the healthcare system. community oncologists for advanced non-small cell lung cancer. The Oncologist, 11; 1095-1099. • Nappa, U., Lindqvist, O., Rasmussen, B., & Axelsson, B. (2011). Palliative chemotherapy during the last month of life. Annals of Oncology, 22; 2375-2380. • Loh, K., Kansagra, A., Shieh, M., Pekow, P., Lindenauer, P., Stefan, M., & Lagu, T. (2017). Predictors of the use of specific critical care therapies in patients with metastatic cancer. JNCCN, 15(1); 22-30. • Magarotto, R., Lunardi, G., Coati, F., Cassandrini, P., Picece, V., Ferrighi, S., Oliosi, L., & Venturini, M. (2011). Reduced use of chemotherapy at the end of life in an integrated-care model of oncology and palliative care. Tumor., 97: 573-577, 5.