Linda L' Emanuel, MD, PhD

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EPEC - OncologySupported by the National Cancer
InstituteAmerican Society for Clinical Oncology
EPEC - O Education on Palliative and End-of-life
Care -Oncology

• Linda L. Emanuel, MD, PhD
• Principal
• Jamie H. Von Roenn, MD
• Charles F. von Gunten, MD, PhD
• Co-Principals
• Frank D. Ferris, MD
• Editor

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Outline

• Policy background
• Charles von Gunten, MD, PhD
• The EPEC Project
• Frank Ferris, MD
• Introduce the EPEC-O Project
• Charles F von Gunten

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EPEC - OncologySupported by the National Cancer
InstituteAmerican Society for Clinical Oncology
Policy Background

• Charles F von Gunten, MD PhD
• Director, Palliative Care
• Associate Professor of Medicine
• University of California, San Diego

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Institute of Medicine, 1997
Approaching Death Improving Care at the End
of Life www.nas.edu/iom 
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ASCO, 1998

• Oncologists responsibility to care for a patient
  in a continuum from diagnosis throughout the
  course of the illness.
• In addition to appropriate anticancer treatment,
  this includes symptom control and psychosocial
  support during all phases of care, including
  those during the last phase of life.

J Clin Oncol 1998161986-96
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National Cancer Policy Board Report , 1999

• RECOMMENDATION 5 Ensure quality of care at the
  end of life, in particular, the management of
  cancer-related pain and timely referral to
  palliative and hospice care.

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National Cancer Policy Board Report , 2001

• Part I Summary and Ten Recommendations
• Part II Eight Commissioned Chapters

www.iom.edu
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NCI-designated cancer centers should play a
central role as agents of national policy in
advancing palliative care research and clinical
practice, with initiatives that address many of
the barriers identified in this report.
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Recommendation 6

• Best available practice guidelines should
  dictate the standard of care for both physical
  and psychosocial symptoms.

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Recommendation 6
Professional societies, particularly the American
Society of Clinical Oncology, should provide
leadership and training for nonspecialists, who
provide most of the care for cancer patients.
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Summary from Policy Background

• NCI and ASCO leadership needed
• Make best evidence practically available
• Role of oncologists as teachers

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The EPEC ProjectEducation for Physicians on
End-of-life Care

• Frank D. Ferris
• Co-Principal, The EPEC Project
• Professor of Medicine
• University of California, San Diego

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Background

• SUPPORT Study, 1995
• Lack of physician competency in end-of-life care
• Target 440,000 practicing physicians in the US

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(No Transcript)
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Method

• Core Curriculum
• Train-the-trainer dissemination
• Exposure for every practicing physician

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EPEC Materials

• Consensus of experts

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Session Format

• 4 Plenaries large group

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Session Format

• 12 Modules small groups

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EPEC Materials

• Trigger Tapes
• Trainers Guide
• Participants Handbook
• Slide Sets
• PowerPoint
• Reproduce with attribution

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Estimated Reach of EPEC Training of first 555
trainers in 2 years

• 6,800 training sessions
• 120,900 health professionals
• 83,138 physicians, residents, medical students

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www.EPEC.net
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Summary from EPEC Project

• Model for dissemination of new information
• Best education science as well as best medical
  science
• Doctors as teachers

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EPEC - OncologySupported by the National Cancer
InstituteAmerican Society for Clinical Oncology
EPEC-O Project Charles F von Gunten, MD,
PHD Associate Professor of Medicine Moores
Comprehensive Cancer Center, UCSD Medical
Director Center for Palliative Studies San Diego
Hospice Palliative Care

• Introduction

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Background to EPEC-O

• ASCO with commitment to palliative care
  throughout the course of the disease
• NCI to eliminate suffering and death by 2015
• Oncologists frequently called upon to teach
  palliative care

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Background to EPEC-O

• Adapt EPEC
• Best scientific evidence
• Best education science
• Train-the-trainer
• Easy to use and flexible materials
• Incorporate Oncology-specific issues

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Imagine
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EPEC - OncologySupported by the National Cancer
InstituteAmerican Society for Clinical Oncology
Gaps in Cancer Care

• Plenary 1

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Principle message

• Gaps between current and desired practice need to
  be filled so that palliative care becomes an
  essential and inextricable part of comprehensive
  cancer care

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Outline

• Describe the current state of palliative care in
  cancer
• Patients / families
• Oncologists
• Describe what is needed
• Introduce the EPEC-O curriculum

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Trigger Video
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Palliative Care

• Treatment to relieve pain and suffering.
• May be combined with therapies aimed at remitting
  or curing cancer, or it may be the total focus of
  care.

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Conventional Cancer Care
Medicare Hospice Benefit
Anti-neoplastic Therapy
Presentation
Death
6m
BereavementCare
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Comprehensive Cancer Care
Hospice Care
Anti-neoplastic Therapy
Palliative Care
Presentation
Death
6m
Symptom Rx Relieve Suffering
BereavementCare
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Gaps

• Large gap between reality, desire

• Fears
• Pain Suffering
• Be a burden
• Loss of control

• Desires
• Be comfortable
• Family able to cope
• Sense of control

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1998 ASCO Survey

• 6,645 oncologists surveyed
• 118 questions
• n 3227 (48 response rate)
• No significant differences in answers based on
  oncology specialty

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Source of Information about palliative care

• 90 Trial and Error
• 73 Colleagues and role models
• 38 Traumatic Experience
• Message No one is teaching this to oncologists

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Inadequate education about palliative care

• 81 inadequate mentor or coaching in how to
  discuss poor prognosis
• 65 inadequate information about controlling
  symptoms

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Personal Failure

• 76 feel some sense of personal failure if
  patient dies of cancer
• 90 feel at least some anxiety discussing poor
  prognosis
• 75 feel at least some anxiety discussing symptom
  control with patients and families

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Unrealistic Expectations

• 29 Patient
• 50 Family
• 27 Conflict

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At least some Influence

• 97 Oncologists reluctant to give up
• 99 Patient / family demands for antineoplastic
  therapy
• 80 Chemotherapy is reimbursable
• 80 Reluctance to talk about issues other than
  antineoplastic therapy
• 91 Takes more time to do palliative care than
  give antineoplastic therapy

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Professional Satisfaction

• 98 some emotional satisfaction to provide
  palliative care
• 92 some intellectual satisfaction to provide
  palliative care
• Marked contrast with preparation and a cause for
  optimism

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Outline

• Describe the current state of palliative care in
  cancer
• Patients / families
• Oncologists
• Describe what is needed
• Introduce the EPEC-O curriculum

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Goals of EPEC-O

• Practicing oncologists
• Core clinical skills
• Improve
• competence, confidence
• patient - physician relationships
• Patient / family satisfaction
• physician satisfaction
• Not intended to make every oncologist a
  palliative care expert

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EPEC-O Curriculum . . .

• conflict resolution
• clinical trials phase I
• preventing professional burnout
• goals of care, treatment priorities

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EPEC-O Curriculum . . .

• symptom management
• diagnosis and prognosis
• advance care planning
• cancer survivorship
• whole patient assessment

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EPEC-O Curriculum . . .

• physician-assisted suicide / euthanasia
• withholding and withdrawing Rx
• Hydration and Nutrition
• care in the last hours of life
• grief and bereavement support
• spiritual and cultural competence

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EPEC-O Curriculum . . .

• how to teach
• models of palliative care
• Next steps to improve palliative care care in
  cancer
• interdisciplinary teamwork (throughout)

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. . EPEC-O Curriculum

• apply each skill in your practice
• enhance professional satisfaction
• foster creative approaches to create change in
  cancer care
• change will not be effective without oncologists

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EPEC for OncologistsSupported by the National
Cancer InstituteAmerican Society for Clinical
Oncology

• Summary
• Gaps need to be filled so that palliative care
  becomes an essential and inextricable part of
  comprehensive cancer care

Plenary 1