COLLABORATION in PALLIATION

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COLLABORATION in PALLIATION

• What to share what to accomplish
• Palliative care values our philosophy
• Caring as a team
• From diagnosis to death
• A review of Quality of Life
• Partnerships
• With patients/families
• With health care professionals
• The NP advantage..

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PALLIATIVE CARE

• Definitions combination of active
  compassionate therapies to comfort support
  individuals families living with, or dying from
  a life-threatening illnessmay be combined with
  therapies aimed at reducing or curing the illness
  or may be the total focus of care excerpted
  from CHPCA definition (2002)
• Hospice palliative care meets the practical
  emotional needs of patients their families

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And a few more to think about...

• Hospice palliative care.
• emphasizes living fully until the end of life in
  comfort with dignity
• Believes that
• dying is an essential human stage of living
  when needs are met the journey toward death
  though difficult can be a rich experience that
  gives meaning to life
• Most studies/literature suggest gt80 of
  palliative patients have a cancer diagnosis

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CANCER is RADICALLY CHANGING.
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A look back historically on the young
science of oncology

• Radiation Oncology as a subspecialty 1976
• Medical Oncology as a subspecialty 1984
• Clinical Trials until 1995 used Overall
  Survival (OS) or Time to Progression (TTP) as
  endpoint in their studies
• 1995 recommendation made for outcome to
  incorporate a Quality of Life measure with OS
  data (Canada first to do this)
• The purpose of medical/surgical intervention is
  to enable patients to live longer (OS), make
  them feel better (Q of L), or both
  Cannistra, JCO, 2004

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MORE HISTORY

• 2000 U.S. FDA convened Q of L sub-committee to
  consider Q of L measurement as standard in
  clinical trials of new cancer agents

Determined that reduction in tumour size may
not be best endpoint for cytostatic
drugs Surely quality of life is more than
shrinking tumours? What is quality of life,
anyway?
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WHAT is QUALITY of LIFE, anyway?

• Meaningful valuable life experiences the
  capacity to have such experiences David Roy, 2003
• Closely tied to autonomy the capacity and right
  to determine our own future Ferris, Flannery,
  McNeal, Morissette, Cameron Bally, 1995
• A patients perception of his/her health
  described in terms of his/her ability to function
  physically, mentally, socially the extent of
  both disease symptoms treatment side effects
  King, Dobson Harnett, 1996
• Patients perception of quality of life more
  aligned with benefits of stabilized disease eg.
  preserved function sense of well-being

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What is stable disease anyway?

• New concept stable disease suggested as more
  realistic desirable endpoint
• Now ALL trials focus on patient survival, time to
  progression quality of life as markers for
  efficacy of drugs increasingly more ? stable
  disease
• Driven by cytostatic agents (target therapy) to
  prevent tumour expansion stabilize disease
• BECAUSE of STABLE disease CANCER now considered
  a CHRONIC DISEASE!!!

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What is CHRONIC DISEASE, anyway?

• A disease marked by long duration
  (Merriam-Webster Dictionary, 2002)
• People with cancer, like individuals with other
  chronic illnesses, are so-called experts in their
  own condition the recognition of this expertise,
  based on user experience should change the
  process of treatment decision-making and could
  change the outcome
  Tritter, 2002
• To support this think about the longevity
  (OS),increased need for rehab, increasingly more
  options for treatment, patterns of waxing/waning
  relapses/remissions
• Some cancers more chronic than others

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Do concepts such as stability/chronicity impact
our practice???

• It should! Longer living has both
  negative/positive outcomes
• Think physical
• psychosocial
• spiritual
• financial
• HUGE impact on prognostication, patient
  participation and decision-making
• We need to start to use the term in practice to
  enable our patients and families to understand
  strive to attain/achieve stability

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A MODEL to BELIEVE IN.
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WHY THIS WORKS in OUR CENTRE

• We are a community hospital
• We have an integrated model
• Care for patients/families from diagnosis ? death
• Know our patients/families for weeks/months/years
• Build relationships of trust respect
• Better/more advocacy opportunities based on
  accurate assessment of needs
• Less isolationism, less fear, less anxiety
  always know who they can reach for support

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Palliative Care is often introduced at the outset
of treatment ie when we first meet the patient

• Patients know chemo/radiotherapy
  palliative/curative intent
• We practice both art and science of
  nursing/medicine/pharmacy
• Care never done in isolation - Always team
  approach
• Many aspects physical, psychosocial, emotional,
  spiritual, etc.
• Advocacy and good information exchange key to a
  good death
• Need to know s s of impending death share
  with family/friends

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Prognosis one of three cornerstones of
medicine(along with diagnosis treatment)

• Prognostication ?modified by treatment
• Treatment options for many types of cancers
  increasing (almost daily)
• Treatment options esp.increasing in pts who are
  at fork in road opt for supportive care /or
  further treatment
• Response to treatment can change prognoses (/-)
• Patients want honesty about severity of illness
  but also want their physicians to be optimistic
  Lamont Christakis, 2003
• 
  

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We care for in-patients/out-patients across
many sites

• We 2 Med. oncologists,
• 4 - Dedicated pharmacists that do
  in-out-patient oncology
• 1 Nurse Practitioner
• 4 Palliative Care Physicians (rotate on
  weekly basis)
• 1 Radiation Oncologist has satellite
  radiation clinic
• Value/expect patients involvement in their care

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Run NP Out-Patient Pain Symptom Management
Clinic True example of partnership

• Held weekly
• See minimum of 6 patients
• Use ESAS with every patient determine major
  concern
• Book each patient for ½ hour
• Work with Pharmacy and MD partner ALWAYS!!
• Rest of team available in this time frame PT,
  Dietitian, CCAC Case Manager, RRT, etc
• Leads to Co-ordinated community care
• Many renewals of Rxs from pharmacies
• Lots of pain pump initiation management
• Lots of calls from community nurses

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Caring in Partnership, contd

• RN(EC) can pronounce and fill in death
  certificate
• Now make home visits when pt does not have PC MD
• Enables more patients to stay at home/die at home
• As new RN(EC) still trying to get handle on LU
  codes, etc
• Pharmacist very helpful with this and renal
  dosing
• MD gives me signed scripts to manage pain/other
  symptoms not covered in Provincial Pharmacy
  privileges
• Copy of all scripts/treatment plans kept and
  letter to Family Practice Physician sent - to
  keep in loop

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LASTLY

• Life is like a string of pearls
• When one is diagnosed with cancer the string
  may be a little shorter
• BUT
• The pearls are no less lustrous!
• J Johnson (1987) cancer survivor

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REFERENCES

• Cannistra (2004),
  Journal of Clinical Oncology
• Ferris, F., Balfour, H., et al., (2003) Norms of
• Ferris, F., Flannery,M., McNeal, H., Morissette,
  Cameron Bally, (1995)
• Fisch, Michael (2005).
• Johnson, J. (1987) Personal communication
  CANO conference Vancouver October
• King, ., Dobson, ., Harnett, . (1996).
• Lamont Christakis(2003)
• Merriam-Webster Dictionary (2002).
• Roy, David (2003).
  Canadian Journal of Palliative Care
• Tritter, . (2002)