The ESMO Palliative Care initiative

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The ESMOPalliative Care initiative

• Nathan I Cherny
• Shaare Zedek Medical center
• Jerusalem, Israel

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ESMO PC/SC Working Group

• Established 1999 by ESMO national representatives
• Chair Prof Raphael Catane
• Activities
• Policy
• Education
• Research
• Quality improvement

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Palliative Care Working GroupActive members
Catane Raphael, Israel
Cherny Nathan, Israel
Grigorescu Alexandru, Romania
Kloke Marianne, Germany
Lange Winand K, Germany
Ozyilkan Ozgur, Turkey
Parikh Purvish, India
Rubach Maryna, Poland
Schrijvers Dirk, Belgium
Szanto Janos, Hungary
Wagnerova Maria, Slovak Republic

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Integration of oncology and Palliative Care ESMO
view

• Medical oncologists role is to coordinate patient
  care at all stages of the disease along with
  other relevant disciplines
• Increasingly oncologists are being marginalised
  because the profession is seen as
  chemotherapists
• To maintain a central coordinating role
  oncologists need to be perceived as cancer
  specialists with a breadth of expertise,
  perspective, and commitment.

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The scope of specialist cancer care

• In advanced cancer
• Palliative anti tumor treatments
• Symptom control
• physical
• psychological
• Family support
• Home care
• End of life care

Unless oncologists take a lead role in the
coordination and implementation of these aspects
of care, we undermine our claim to be cancer
care specialists.
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Policy
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Definition of Terms

• Supportive Care
• care that optimizes comfort, function and social
  support of patient (and family) at all stages of
  illness
• Palliative Care
• care that optimizes comfort and function and
  social support of patient (and family) when cure
  is not possible
• End of Life Care
• palliative care when death is imminent

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PotentiallyCurable
Non-Curable
Terminal
Diagnosis
Supportive Care
Palliative Care
EoL Care
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Care Integration with Disease Evolution
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The Role of the Oncologist in the Provision of
Supportive and Palliative Care

• The Medical Oncologist must be skilled in the
  supportive and palliative care of patients with
  cancer and in end-of-life care.
• It is the responsibility of the MO to assess and
  evaluate physical and psychological symptoms and
  to ensure that these problems are adequately
  addressed.
• The delivery of high quality supportive and
  palliative care requires co-operation and
  coordination with
• physicians of other disciplines
• (including radiotherapy, surgery, rehabilitation,
  psych-oncology, pain medicine and anesthesiology,
  palliative medicine etc)
• paramedical clinicians
• (including nursing, social work, psychology,
  physical and occupational therapy, chaplains and
  others).

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Supportive and Palliative Care training for
Medical Oncologists

• Medical Oncologists must be skilled in the
  supportive and palliative care of patients with
  advanced cancer.
• 9 core skills must be incorporated.

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1.The oncologic management of advanced cancer

• Medical oncologists must be expert in the
  appropriate use of anti tumor therapies as
  palliative techniques when cure is no longer
  possible.
• This includes specific familiarity with key
  concepts
• patient benefit
• quality of life
• risk/benefit analysis

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2. Communication with patients and family members

• Medical oncologist must be skilled in effective
  and compassionate
• communication with cancer patients and their
  families.
• Specific skills include
• Explaining diagnosis and treatment options
• Disclosure of diagnosis
• Explaining issues relating to prognosis
• Explaining the potential risk and benefits of
  treatment options
• Counseling skills to facilitate effective,
  informed decision making.
• Explaining the role of palliative care
• The care of distressed family members fear,
  anticipatory grief, bereavement care
• Convening of family meetings

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3. The management of complications of cancer

• Medical oncologists must be expert in the
  evaluation and management of the complications of
  cancer including
• Bone metastases
• CNS metastases
• Neurological dysfunction tumoral, paraneoplastic
  and iatrogenic
• Liver metastases and biliary obstruction
• Malignant effusions
• Obstruction of hollow viscera
• Metabolic consequences of cancer
• Anorexia and cachexia
• Hematologic consequences
• Sexual dysfunction

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4. Evaluation and management of physical symptoms
of cancer and cancer treatment

• Medical oncologists must be expert in the
  evaluation and management of the common physical
  symptoms of advanced cancer including
• Pain
• Dyspnea and cough
• Fatigue
• Nausea and Vomiting
• Constipation
• Diarrhea
• Insomnia
• Itch

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5. Evaluation and management of psychological and
existential symptoms of cancer

• Medical oncologists must be familiar with the
  evaluation and management of the common
  psychological and existential symptoms of cancer
  including
• Anxiety
• Depression
• Delirium
• Suicidality and desire for death
• Death anxiety
• Anticipatory grief

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6. Interdisciplinary care

• Medical oncologists must be familiar with the
  roles of other professions in the care of
  patients with cancer and with community resources
  to support the care of these patients.

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7. Palliative care research

• Medical oncologist must be familiar with research
  methodologies that are applicable to patients
  with cancer including
• Quality of life research
• Pain measurement and research
• Measurement of other physical and psychological
  symptoms
• Needs evaluation
• Decision making research
• Palliative Care audit

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8. Ethical issues in the management of patients
with cancer

• MOs must be familiar with common ethical problems
  and ethical principles that assist in their
  resolution
• Related to disclosure of diagnosis and prognosis
• In decision making paternalism, autonomy,
  informed consent
• The right to adequate relief of physical and
  psychological symptoms and its implications
• Consent informed, uninformed
• Ethical issues at the end of life
• Foregoing treatment
• Euthanasia, assisted suicide

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9.Preventing Burnout

• Medical oncologist must be familiar with the
  symptoms of burnout, the factors that contribute
  to burnout and strategies to prevent its
  development.

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Minimal requirements palliative care in cancer
centers 1

• Patients should be routinely assessed regarding
  the presence and severity of physical and
  psychological symptoms and the adequacy of social
  supports
• When inadequately controlled symptoms are
  identified they must be evaluated and treated
  with the appropriate urgency
• Cancer center must provide skilled emergency care
  of inadequately relieved physical and
  psychological symptoms.

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Minimal requirements palliative care in cancer
centers 2

• Cancer centers must ensure an ongoing program of
  palliative and supportive care for patients with
  advanced cancer who are no longer benefited by
  anti-tumor interventions.
• Cancer centers should incorporate social work and
  psychological care as part of routine care.
• When patients require inpatient end of life care,
  the cancer center staff either provide the needed
  inpatient care or arrange adequate care in an
  appropriate hospice or palliative care service.

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ResearchESMO Palliative and Supportive Care
Survey
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AIMS

• to evaluate
• the degree to which ESMO oncologists are involved
  in the management of advanced cancer
• the degree with which they collaborate with PC
  clinicians
• their personal involvement in PC
• their attitudes to PC

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Survey tool

• Demographics
• age
• sex
• experience
• place of work
• involvement in advanced cancer

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Survey tool 2

• Collaboration with SC/PC
• 7 items
• Practice of SC/PC
• 16 items
• Attitudes
• 24 items

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Demographics 1

• N895/3300
• European 82.4
• Sex F 194 (21.7) M 701 (78.3)
• Median age 45-49
• Median experience 15-19 years

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Practice Type

• Private oncology practice 167 18.7
• Community hospital based 176 19.7
• Teaching hospital based 334 37.3
• Comprehensive cancer center 185 20.7
• Other 33 3.7

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Proportion of my practice involved with advanced
(incurable) cancer

• None 4 0.4
• A small proportion 78 8.7
• A substantial proportion 615 68.8
• Most of my practice 197 22.0

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Key findings

• Most medical oncologists are clinically involved
  with patients with advanced cancer
• The attitudes of responding members correspond
  closely with the proposed ESMO policy statements
  relating to Supportive Care/Palliative..
• oncologist role
• education
• integration of SC/PC in cancer centers

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Attitudes

• Most MOs believe that
• oncologists should coordinate care the care of
  patients with advanced cancer including EoL care
• SC/PC should be initiated in all patients when
  need is identified
• oncologists should be expert in physical and
  psych SC/PC
• all cancer centers should provide SC/PC

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Discrepancy Between Attitude and Practice

• Although, 88.4 agreed medical oncologists should
  coordinate the care of cancer patients at all
  stages of disease including end of life care...
• Actual practice seems much less...
• 43 commonly coordinate the care of cancer
  patients at all stages of disease including end
  of life care.
• 39 commonly coordinate meetings with the family
  of dying patients
• 11.8 manage delirium

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PC Collaboration

• often
• A social worker 47.9
• A home hospice (palliative care) team 37.8
• A palliative care medical specialist 35.1
• A psychologist 33.3
• A palliative care nurse specialist 31.7
• An inpatient hospice 26.4
• A psychiatrist 14.9

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Attitudes No Consensus
Agree
Disagree

• I received good training in PC during my oncology
  fellowship (residency)
• I feel emotionally burned out by having to deal
  with too many deaths.
• Most MOs I know are expert in the management of
  the physical and psychological symptoms of
  advanced cancer.
• A palliative care specialist is the best person
  to coordinate the palliative care of patients
  with advanced cancer.
• Palliative care (or Hospice) physicians dont
  have enough understanding of oncology to counsel
  patients with advanced cancer regarding their
  treatment options.

52.8 33.8 37.5 36.3 35.2
42.0 55.6 41.8 39.4 39.2
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Program Development Incentives
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Committee for education

• The incorporation of palliative medicine in the
  curricular requirements for ESMO certification
  and accreditation.
• Inclusion in the ESMO examinations questions on
  all aspects of cancer palliation
• Special Advanced training Fellowship Programs
  designed to focus on research and clinical
  application of palliative Care.

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Designated centers of excellence

• Incentive program
• Encouragement through the identification and
  support of model programs
• Clinical programs accredited as center of
  excellence will be supported as foci of
  education and research and will be endorsed as
  centers of excellence in integrated care.

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Designated Centers Program

• BENEFITS
• TitleRecognition
• PC Fellowships
• Special Grants

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Criteria for Designated Centers

• The Center provides closely integrated oncology
  and palliative care clinical services
• The Center is committed to a philosophy of
  continuity of care and non-abandonment
• The Center provides high level home care with
  expert backup and coordination of home care with
  primary cancer clinicians
• The Center incorporates programmatic support of
  family members.

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Criteria for Designated Centers

1. The Center provides routine patient assessment of
   physical and psychological symptoms and social
   supports and has an infrastructure that responds
   with appropriate interventions in a timely manner
2. The Center incorporates expert medical and
   nursing care in the evaluation and relief of pain
   and other physical symptoms
3. The Center incorporates expert care in the
   evaluation and relief of psychological and
   existential distress

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Criteria for Designated Centers

• The Center provides emergency care of
  inadequately relieved physical and psychological
  symptoms
• The Center provides facilities and expert care
  for inpatient symptom stabilization
• The Center provides respite care for ambulatory
  patients for patients unable to cope at home or
  in cases of family fatigue

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Criteria for Designated Centers

1. The Center provides facilities and expert care
   for inpatient end-of-life care and is committed
   to providing adequate relief of suffering for
   dying patients
2. The Center participates in basic or clinical
   research related to quality of life of cancer
   patients
3. The Center is involved in clinician education to
   improve the integration of oncology and
   palliative care

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Selected Designated Centers

1. Velindre NHS Trust, Cardiff UK Ilora Finlay
2. AZ Middelheim, Antwerp Belgium Dirk Schrijvers
3. Istituto Oncologico della Svizzera Italiana,
   Ospedale San Giovanni, Bellinzona Switzerland
   Piero Sanna
4. Kliniken Essen-Mitte, Essen Germany Marianne
   Kloke
5. Vicenza General Hospital, Vicenza Italy Leonardo
   Trentin
6. Cork University Hospital, Wilton, Cork Ireland
   Oscar Breathnach
7. Klinik Dr. Hancken GmbH, Stade Germany A.
   Scherpe
8. O.D.O. AVAPO, div. Oncologia medica, osp. SS.
   Giovanni e Paolo, Venezia Italy Ardi Pambuku

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Future Plans
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Plans

• Education
• India
• Pakistan Mexoco
• Eastern Europe
• Routine ESMO courses

• Collaborative program development
• EAPC
• MASCC
• ASCO
• India
• Eastern Europe

• Research
• Communication practices
• Defining standards for BSC