The Oncology Palliative Care Interface

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The Oncology Palliative Care Interface Powered By Docstoc
					The Oncology-Palliative Care Interface

David E. Weissman, MD Division of Neoplastic Diseases

Palliative Care Program
Medical College of Wisconsin

Full disclosure


1983-1996
– Academic medical oncologist; general and neurooncology

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1992-2000
– Community hospice medical director

1993-present
– Academic palliative care physician

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2009
– Cancer survivor

“What we've got here is a failure to communicate” Luke, Cool Hand Luke
1967

What are we talking about?
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Oncology
– Care of cancer patients

Oncologist
– Medical
– Radiation – Surgical – GYN – Neuro

The Problem
Two ‗species‘ trying to occupy the same ecological niche, resulting in …
 Misunderstanding
 Conflict  Anger

From the Palliative Care staff…
    

Why don’t they refer patients sooner.
I know what’s best for the patient They don’t understand what palliative care is all about. If they’d only be honest with their patients All they care about is money.

From the oncologist …
    

I already do palliative care. They (palliative care) are all about death, I’m here to save patients. I provide chemotherapy if my patient wants it. I don’t want to upset the patient by discussing prognosis. I don’t get paid to have conversations.

What Is Conflict?


Conflict is a disagreement resulting from individuals or groups that differ in attitudes, beliefs, values or needs. Values are beliefs or principles we consider to be very important. Serious conflicts arise when people hold incompatible values or when values are not clear.

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Values
Oncology
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Palliative Care
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Longer life
– Never give up

Quality life
– Death is normal

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Physician directed Guarded disclosure
– Protect the patient

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Team supported Full disclosure
– Patient knows

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Savior from death

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Savior from too much medical care

But, that‘s not me!!!


It may not be, oncologists span a range of attitudes/values/cultures:
– Biomedical oriented
• The disease is the focus

– Biopsychosocial oriented
• The patient is the focus

When I was program director …
―what does an oncologist do‖
 

Wrong answer:
– they diagnose and treat cancer

Right answer:
– they care for patients with cancer

Values in Common
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Living the best life possible
– Keeping patients functional – Reducing symptom burden – Supporting patients and families emotionally

How do values form?
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Direct instruction
Pressure to conform
– Rewards and punishments

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Experiences
– Pre-training – Training

– Practice

How do values change?
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 

Openness; ready for change
Practice with reflection/feedback Role modeling

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Shared experiences

Curriculum
Oncology
 

Palliative Care
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Cancer biology/epi Cancer diagnostics

Symptom management Communication

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Cancer treatments
Oncological emergencies End-of-life care
– Symptom management – Psychosocial – Ethics

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Natural xPrognosticationEthics/Law Psychosocial aspects

Community resources

Skills
   

Oncology Anti-cancer agent administration

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Palliative Care Emergency symptom control

Bone Marrow Bx
IT Injections Para/Thora centesis

Family conference
DNR discussion Ventilator withdrawal Sedation for refractory symptoms

Models of PC-Oncology Practice
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Consultation
– Specific problem: pain

Co-management
– Ongoing care by both

Referral
– End of chemotherapy

Needs of the cancer patient
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  

Symptom issues
Mental health issues Goal of care issues
– When is enough, enough?

Family dynamic/support issues

Old

Life Prolonging Care

Hospice Care

Life Prolonging
New

Care

Hospice

Palliative Care

Care

Dx

Death

Preferred Model of Care

 

Co-Management
– Primary vs. Tertiary Palliative Care

Starting early in the disease course
– Driven by the needs of the patient/family

Medical criteria for collaboration
– Complex symptom management

– Prognosis/Functional Status/Disease progression
– Support/Coping/Decision

Addressing the fears



The patient is “not ready” for palliative care
Referral will make the patient lose hope

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Talking about prognosis will result in a self-fulfilling prophecy
They will talk the patient out of more chemotherapy

Patients who have the ―dying‖ talk…
 

No difference in mental health or worry; does not remove HOPE Less likely to
– want heroic measures – undergo ventilation

– be admitted to ICU


More likely to
– complete DNR – use hospice – reduce unnecessary care
Wright A, et al. JAMA. 2008;300:1665-73 ,Zhang B, Arch Int Med 2008

What‘s the benefit for the oncologist?
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Support for challenging symptoms
Time management
– symptom control

– coping/support

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Assistance with difficult communication encounters
– typically for patients who are not accepting of their impending death

MCW Cancer Center
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Palliative Care Clinic
– 3 days/week scheduled patients
• PC Staff/Fellow/APN/Psychologist

– 5 days/week Pall Care ANP in clinic for walk-ins

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90% co-management cases with oncologist—spans disease trajectory
Referral pattern not criterion based
– Solid tumor >>>>> other

Educational Issues


Palliative Care must be a core component of oncology training (and vice versa)
– Required clinical training in palliative care under supervision of B/C Palliative Care physicians – Major emphasis on symptom management and communication skills – Communication skills must be taught using experiential methods with direct feedback.

OncoTalk
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Training for Oncology Fellows in cancer communication skills
2009/2010 Full

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http://depts.washington.edu/oncotalk/re gister.html


				
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