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The ESMO Palliative Care initiative

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Medical oncologists role is to coordinate patient care at all stages of the ... Neurological dysfunction: tumoral, paraneoplastic and iatrogenic ... – PowerPoint PPT presentation

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Title: The ESMO Palliative Care initiative


1
The ESMOPalliative Care initiative
  • Nathan I Cherny
  • Shaare Zedek Medical center
  • Jerusalem, Israel

2
ESMO PC/SC Working Group
  • Established 1999 by ESMO national representatives
  • Chair Prof Raphael Catane
  • Activities
  • Policy
  • Education
  • Research
  • Quality improvement

3
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

4
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.

5
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.
6
Policy
7
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

8
PotentiallyCurable
Non-Curable
Terminal
Diagnosis
Supportive Care
Palliative Care
EoL Care
9
Care Integration with Disease Evolution
10
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).

11
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.

12
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

13
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

14
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

15
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

16
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

17
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.

18
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

19
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

20
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.

21
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.

22
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.

23
ResearchESMO Palliative and Supportive Care
Survey
24
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

25
Survey tool
  • Demographics
  • age
  • sex
  • experience
  • place of work
  • involvement in advanced cancer

26
Survey tool 2
  • Collaboration with SC/PC
  • 7 items
  • Practice of SC/PC
  • 16 items
  • Attitudes
  • 24 items

27
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

28
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

29
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

30
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

31
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

32
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

33
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

34
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
35
Program Development Incentives
36
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.

37
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.

38
Designated Centers Program
  • BENEFITS
  • TitleRecognition
  • PC Fellowships
  • Special Grants

39
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.

40
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

41
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

42
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

43
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

44
Future Plans
45
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
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