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A Transformative Year for Palliative Care Top Practice Changing (or Practice Validating) Articles 2013-2014

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Title: A Transformative Year for Palliative Care Top Practice Changing (or Practice Validating) Articles 2013-2014


1
A Transformative Year for Palliative CareTop
Practice Changing (or Practice Validating)
Articles 2013-2014
  • Russell Goldman MD, MPH, CCFP
  • Ramona Mahtani MD, CCFP

2
Disclosure past 2 years
  • April 2014 pain management in the elderly for
    oncologists sponsored by Purdue
  • December 2013 Advisory Board participant for
    Teva Pharmaceuticals on SL fentanyl

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Transformative Paradigm in Palliative Care
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Whats Already Known
  • Many patients with metastatic cancer receive
    chemotherapy in their final months WITHOUT
    information on survival, future care, quality of
    life and location of death
  • Patients who receive chemo within 2 weeks of
    death are less likely to receive hospice
    services, compared with those who do not

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Objective of Study
  • Is there an association with chemotherapy in
    patients last MONTHS of life and intensive
    medical care in the ICU in their last WEEK?
  • -More likely to die in ICU?
  • -More likely to receive CPR, mechanical
    ventilation, both?
  • -Late referrals to hospice (home palliative
    care/PCU)?
  • -Less likely to die in preferred place?

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Methods
  • Participants baseline Interview
  • Medical Chart Review at study enrollment
  • Confirmation with Physician performance status
    and prognosis lt6mo

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Additional Covariates Measured at Baseline
  • Sociodemographic characteristics
  • Health Status Measures
  • McGill Quality of Life Index, Charlson Comorbid
    Index, ECOG, Karnofsky score
  • Treatment preferences

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Sample Patient Interview
  • If you could choose, would you prefer
  • 1) a course of treatment that focused on
    extending life as much as possible, even if it
    meant more pain and discomfort, or
  • 2) on a plan of care that focused on relieving
    pain and discomfort as much as possible, even if
    that meant not living as long?
  • Would you take chemotherapy and risk side
    effects such asor have to spend more time in the
    hospital if it would keep you alive for ___
    time

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  • Q for Patient Do you think it would be a bad
    thing for a person to die in the ICU versus
    elsewhere (e.g., home, hospital, and hospice)?
  • Q for Caregiver Do you think that (PLACE OF
    DEATH) was where (PATIENT) would have most wanted
    to die?

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Results
  • 56 participants were receiving palliative chemo
    on study enrollment (N386)
  • Died median of 4 months (1.8-8.3 m0) after
    enrollment in study
  • Survival same in both groups

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Total Yes Chemo No Chemo
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  • What do you think?

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Authors conclusions
  • Our study has important implications for oncology
    providers, patients with advanced cancer, and
    caregivers facing decisions about treatment. It
    suggests that end of life discussions may be
    particularly important for patients receiving
    palliative chemotherapy, who should be informed
    by data on the likely outcomes associated with
    its use. The findings also suggest the need for
    oncology providers to elicit patients preferred
    site of death to ensure that patients end of
    life experiences are congruent with their values.

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  • Palliative Chemotherapy as an exclusion
    criteria for Palliative Care Programs?
  • Time-outs involving interdisciplinary
    interprofessional teams to reflect avoid
    inadvertently treating ourselves in offering
    interventions without benefit with potential to
    harm at end of life

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  • Advance Care Planning discussions need to
    consider the longer-term path patients and
    familys are sent on when decisions are made
    earlier in their disease trajectory

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Emerging, Practical Evidence Base
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Purpose
  • Cancer patients at end of life majority in
    hospital receive parenteral hydration majority
    in hospice do not
  • Limited evidence supporting either practice
  • RCT to determine the effect of hydration on
    symptoms associated with dehydration, quality of
    life, and survival in patients with advanced
    cancer

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Methods
  • Intervention
  • 1000 ml SC daily over 4 hours
  • Control
  • 100 ml SC daily over 4 hours
  • Blinding different nurse started infusion pump
    in a backpack with counterweight
  • End point
  • Unresponsive progressive coma or died

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Measures
  • fatigue, myoclonus, sedation, hallucinations,
    pain, nausea, depression, anxiety, drowsiness,
    shortness of breath, appetite, feelings of
    well-being, and sleep, was assessed using the
    Edmonton Symptom Assessment Scale (ESAS)
  • Primary outcome change in sum of four dehydration
    symptoms (bold) day 4 and baseline

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Measures (cont)
  • Memorial Delirium Assessment Scale
  • Richmond Agitation Sedition Scale (RASS)
  • Nursing Delirium Screening Scale (NuDESC)
  • Unified Myoclonus Rating Scale (UMRS)
  • QoL and fatigue during the last 7 days using the
    Functional Assessment of Chronic Illness
    TherapyFatigue (FACIT-F) questionnaire.
  • Physical assessement (mucous membranes, axillary
    moisture sunkenness of eyes
  • Baseline, day 4 and then q3-5 days

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Results
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Results
  • No significant differences between the two groups
    for
  • Change in the sum of four dehydration symptoms
    (-3.3 v -2.8, P .77), ESAS (all nonsignificant)
  • MDAS (1 v 3.5, P .084),
  • NuDESC (0 v 0, P .13),
  • UMRS (0 v 0, P .54) by day 4.
  • Results for day 7, including FACIT-F, were
    similar
  • Survival did not differ between the two groups
    (median, 21 v 15 days, P .83).

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What do you think?
35
Authors Conclusions
  • In conclusion, our results suggest that in
    patients with advanced cancer who are mildly to
    moderately dehydrated and within days to weeks of
    death, parenteral hydration at 1,000 mL per day
    does not improve symptoms associated with
    dehydration, QoL, or survival as compared with
    placebo.

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Authors Conclusions (cont)
  • Our study supports current hospice practice of
    not administering hydration routinely. Further
    studies are required to determine whether any
    subgroups, such as delirious patients or those
    with longer survival, would benefit from
    parenteral hydration

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Whats already known
  • Cochrane Review (2010) mixed results for all
    pharmacologic treatment vs. placebo for CRF
  • Prior positive studies did not use validated
    outcome measures, not adequately powered
  • No Double-Blind, Randomized Placebo Controlled
    Trial

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  • Primary Objective Effect of Dexamethasone and
    Placebo on CRF using validated instrument
  • Secondary Objective Role of Dexamethasone in
    anorexia, anxiety, depression and symptom
    distress scores
  • Location Outpatient clinic for pain management,
    palliative care, Oncology at 4 unique sites

40
Inclusion Criteria
  • Advanced cancer
  • Moderate to Severe CRF clinical cluster symptoms
    3 symptoms during previous 24hrs (pain,
    fatigue, nausea, anorexia/cachexia, sleep
    problems, depression, poor appetite) with 4 on
    ESAS
  • Normal cognition
  • No infection
  • Hemoglobin gt90 within week of enrollment
  • Life expectancy 4 weeks
  • No AIDS
  • ANC 750 within week of enrollment
  • No diabetes in last 2 weeks and no surgery in
    last 2 weeks

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Intervention
  • Dexamethasone 4mg OR Placebo po bid x 14d

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Outcome Measures
  • FACIT-F
  • validated, quality of life instrument (CRF
    clinical trials)
  • 27 general quality of life questions divided into
    4 domains (physical, social, emotional,
    functional)
  • 13 item FACIT-F fatigue subscale
  • FAACT
  • ESAS
  • HADS
  • Monitored for Adverse Events (National Cancer
    Institute Common Toxicity Criteria)

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No interest Too much burden25
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Mean Difference 5.9
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Mean difference -6.0
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  • What do you think?

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Limitations!
  • Dose
  • Duration
  • Beyond 2 weeks -- Effects wane, Adverse effects
    increase
  • Cluster Symptoms
  • Not assessing an integrated holistic,
    multidisciplinary approach

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  • Diagnose underlying multifaceted processes
    involved in fatigue
  • Physical (dexamethasone responsive?) VS.
    Emotional, Relationships, Spiritual, Functional
  • Consider pain control, exercise, sleep hygiene,
    nutrition

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Transforming Care through Development of Quality
Indicators
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  • IMPORTANCE Characterizing the quality of
    supportive cancer care can guide quality
    improvement.
  • OBJECTIVE To evaluate nonhospice supportive
    cancer care comprehensively in a national sample
    of veterans.

59
Design Setting and Participants
  • Retrospective cohort stage IV pancreatic,
    colorectal and lung cancer
  • 719 Veterans in 2008
  • Measured evidence based supportive care using
    Cancer Quality ASSIST Indicators
  • pain, nonpain symptoms, and information and care
    planning

60
Cancer Quality ASSIST Examples
  • If a cancer patient has a cancer-related
    outpatient visit then there should be screening
    for the presence or absence and intensity of pain
    using a numeric pain score
  • If a patient with cancer pain is started on a
    long-acting opioid formulation, then a
    short-acting opioid formulation for breakthrough
    pain should also be provided

61
  • If an outpatient with cancer not receiving
    chemotherapy or radiation is treated for nausea
    or vomiting with an antiemetic medication, then
    the effectiveness of treatment should be
    evaluated before or on the next visit to the same
    outpatient site
  • If a patient with advanced cancer dies an
    expected death, then s/he should have been
    referred for palliative care prior to death
    (hospital-based or community hospice) or there
    should be documentation why there was no referral

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Results (just a sample)
  • 719 veterans triggered a mean of 11.7 quality
    indicators (range, 1-22) and received a mean
    49.5 of appropriate care.
  • inpatient pain screening 96.5 vs outpatients
    58.1
  • Few patients had a timely dyspnea evaluation
    (15.8) or treatment (10.8)

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Results
  • With opioids, bowel prophylaxis 52.2 of
    outpatients vs 70.5 of inpatients.
  • Of patients at high risk for diarrhea from
    chemotherapy, 24.2 were offered appropriate
    antidiarrheals
  • 17.7 of veterans had goals of care addressed in
    the month after a diagnosis of advanced cancer,
    and 63.7 had timely discussion of goals
    following intensive care unit admission.
  • 86.4 of decedents were referred to palliative
    care or hospice before death.

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What do you think?
  • Indicators?
  • Applicability to our cancer centres?
  • Take aways?

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Conclusions
  • Development of a toolkit to support quality
    improvement in supportive and palliative care

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Implications for the Health Care System
  • One important implication is that tools are
    available to assess the extent to which
    supportive care quality might be better or worse
    outside the VA. Given the National Quality Forum
    endorsement of Cancer QualityASSIST indicators
    as well as other similar measures, such as those
    from the Quality Oncology Practice Initiative in
    recent standards, our results support the
    application of the Cancer QualityASSIST
    indicators more widely

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Summary
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