Beyond Advance Directives: The Oncologist’s Role in Primary Palliative Care

1. Beyond Advance Directives: The Oncologist’s Role in Primary Palliative Care David B. Brecher, M.D.,FAAFP Adult Palliative Medicine Service Tacoma General Hospital MultiCare Health System Washington State Medical Oncology Society Conference Seattle, WA Nov 16, 2012

2. Objectives • Understand the difference between Hospice and Palliative Care • Discuss the expanding need for a Palliative Care approach in oncology • Consider strategies to use when “giving bad news” • Techniques to discussing advance directives

3. Case: Introduction • 72 Year old male “Mike” • Pancreatic CA 11/2011 • Liver METS 04/2012 • Widower • 2 Sons • 1 Daughter – patient lives with her • Has a faith affiliation • NO DPOA-H • NO AD – Full Code • Admitted: N/V, weight loss • Goals?

4. Weissman, D. (2005)

5. Hospice Care • Patients have a life expectancy of 6 months or less • Patient and family are the focus of care • Interdisciplinary team • Usually in the patient’s “home”

6. Palliative Medicine vs. Hospice

7. Integration of Palliative Care into Standard Oncology Care • Combined standard oncology care and palliative care early in the course for any patient with metastatic cancer • Utilize palliative care and standard oncology care to optimize quality of life, survival, and help to minimize costs

8. Oncology-Palliative Care Interface • Increasing recognition that Palliative Care = Excellent Oncology Care (US News Best Hospitals Criteria) • Emphasis on patient values and goals (Kaldjian 2008) • Patients prefer to focus on values and goals, rather than procedures (Hawkins 2005)

9. What is Palliative Medicine? Palliative Medicine provides symptom management to patients with debilitating acute or chronic disease, and/or life threatening illness Palliative Medicine focuses on providing relief of physical, psychosocial, and spiritual pain (relief of “total pain”) (Cicely Saunders, MD) There is never “nothing else that can be done…”

10. Value of Palliative Care • Improves quality of life • Reduces major depression • Less aggressive EOL care • Patients live longer, and with better outcomes (11.6 months vs 8.9 months, p < 0.02) (Temel 2010)

11. “Palliative Care is about matching treatment to patient goals” Diane Meier, MD

12. Shared Medical Decision Making • Patient/Surrogate • Medical Team (“all on the same page”) • The Medical Team can (has an obligation to) make a recommendation as to what medical care is most likely to achieve the patient’s goals, and therefore what is appropriate

13. Tools • Time limited trial with defined goals • “Hope for the best, and meanwhile prepare for the worst…”

14. End-of-Life Experiences for Cancer Patients

15. End-of-Life Conversations “It’s too early until it’s too late.”

16. End-of-life discussions are a high-value clinical intervention

17. Identify Triggers: Cancer • Prognosis-related triggers Stage 4 Disease PPS < 40%/ECOG > or = 3 • Disease-based/condition-based criteria, e.g.: All patients with NSCLC, pancreatic cancer, GBM Patients over 70 with AML • Treatment-based identification Failed second line therapy Enrolled in a clinical trial (NCCN 2011 Guidelines)

18. The end-of-life experience of cancer patients • Patients who receive hospice care report better quality of life • Aggressive care is associated with reduced quality of life, physical and emotional distress (Dartmouth Atlas – 2003 to 2007 data)

19. Cancer Patients and EOL Discussions • Only 37% of cancer patients with average survival of 4 months reported having had discussion about EOL issues with physician (Wright 2008) • Although 95% of hospitalized oncology patients believe it is important to have discussions about advance directives/EOL care, only 41% have them • Major barrier: Oncologists don’t bring up issue (Dow 2010)

20. Improving Quality • Early discussion of end-of-life care issues among cancer patients is associated with improved outcomes: • Patients more likely to have wishes followed • Increases quality of life • Reduces rate of hospitalization and ICU admission • Increases use of hospice • Reduces stress, anxiety, depression, PTSD and bereavement morbidity in survivors • Improves family satisfaction (Wright 2008)

21. Delivering “Bad News”

22. Six Steps • Getting Started • Finding out how much the patient knows • Finding out how much the patient wants to know • Sharing the information • Responding to the patient’s/family’s feelings –– Don’t say “I know how you feel” • Planning and follow-through

23. Discussing Advanced Directives

24. Learning Objectives • Know why it is important to discuss Advance Directives status with patients/families • Know how to discuss Advance Directives status – Make a Recommendation • Know how to document Advance Directives status

25. The Surprise Question • Would you be surprised if this person died in the next 6-12 months? • (Then let’s make sure the patient, family, caregiver, guardian…is not surprised either)

26. Advance Directives • Code status preference – just part of it • Durable Power of Attorney for Health Care Decisions – (DPOA-H) • Living Will * Withhold or Withdraw life-sustaining treatment * Artificial Nutrition & Hydration • Physician Orders for Life Sustaining Treatment – (POLST)

27. Surrogate Decision Maker • DPOA-H • Decision Making Capacity - Not “competency” • Substituted judgment - If the patient was able to speak for themselves today, how would they answer these questions?

28. DNAR: Who Initiates? • Oncologists are in the ideal position to initiate DNR discussions • Patients typically rely on their oncologists to initiate the discussion, as they often serve as patient’s PCP • Patients/families often think a lot about dying – they are often awaiting permission to talk about it – “the elephant in the room”

29. Acknowledge the Elephant in the Room • “This is a life-threatening Illness” • “You are at high risk for dying from this malignancy”

30. DNAR: How – Establish patient goals/expectations Treatment Goals: • “Given the severity of your illness, what is most important to you right now?” • “How do you think about balancing quality of life with length of life in terms of your treatment?” • “What are your biggest fears/concerns?” • “What are your hopes for the future?”

31. DNAR Discussion • Often a facilitated family discussion • “How much do you want to know?” • Get the patient/family talking – use open-ended questions (i.e. “Ask – Tell – Ask”) • Talk less, listen more

32. HOW – Statements to Avoid • “Do you want us to do everything” – Implies that without CPR we will “do nothing” • “There’s nothing else that can be done” There is always a lot that can be done to provide physical, emotional, and spiritual support

33. Barriers • We avoid the concept of Death • Physicians are often overly optimistic about prognosis • Unrealistic belief in technologic solutions • Loss of hope for the future • If no CPR – “nothing will be done” • It takes too much TIME to talk about…

34. Key Points in Discussing Advance Directives • Explore the patient’s understanding of their illness • Explore the patient’s values and expectations • Understand the likely outcome of CPR • Make a recommendation consistent with the patient’s goals • Check for patient/family understanding • Do not force a decision – be sure to follow-up/try to establish a relationship • Continue to provide good medical care to support physical, emotional and spiritual needs • Address other related issues (Eventually) -DPOA-H -POLST -Living Will i.e. role of Artificial fluid/nutrition -Five Wishes -Hard Choices

35. Case: Conclusion Goals: • To go to his daughter’s home • Remain independent • Make a recommendation?

36. Palliative Medicine Resources • Center to Advance Palliative Care www.capc.org • National Hospice and Palliative Care Org www.nhpco.org • American Academy of Hospice and Palliative Medicine www.aahpm.org • Hard Choices for Loving People, Dunn, H, A & A Publishing, Inc, 5th Ed. 2009 • EPERC (End of Life/Palliative Education Resource Center, www.eperc.mcw.edu

37. References • Back AL, Arnold, RM, MD; Quill TE, Hope for the Best, and Prepare for the Worst, Ann Intern Med. 4 March 2003;138(5):439-443  • Block, S, Moving Conversations about the End of Life Upstream: A Systems Approach, University of Washington, October 2012 • Dartmouth Atlas, The Dartmouth Institute For Health Policy & Clinical Practice, http://www.dartmouthatlas.org • Dow LA, Matsuyama RK, Ramakrishnan V, et al. (2010) Paradoxes in advance care planning: The complex relationship of oncology patients, their physicians, and advance medical directives. J Clin Oncol 28:299–304 • Ferris F, Bruera E, Cherny N, Cummings C, Currow D, Dudgeon D, et al. (2009) Palliative Cancer Care a Decade Later: Accomplishments, the Need, Next Steps—From the American Society of Clinical Oncology, JCO, vol. 27 no. 18 3052-305 • Kaldjian LC, Curtis AE, Shinkunas L, Cannon KT.  Goals of care toward the end of life: a structured literature review.  American Journal of Hospice and Palliative Medicine 2009;25:501-511. • National Comprehensive Cancer Network Guidelines, “Palliative Care” Version 2.2011, NCCN.org • Smith T, Temin S, Alesi E, Abernethy A, Balboni, T, Basch, E, et al. (2012) American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of Palliative Care Into Standard Oncology Care JCO vol. 30 no. 8 • Temel JS, Greer JA, Muzikansky A, et al. (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733–742. • Weissman, D, Palliative Care Improving Quality and Reducing Cost, 2008, Center to Advance Palliative Care, www.capc.org • Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL, Jackson VA, Block SD, Maciejewski PK, Prigerson HG, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008 Oct 8;300(14):1665-73.

38. Questions?

39. Thank you!