Oncologist's Role in Palliative Care Flashcards
Overall cure rate for cancers
60%
Integration of palliative medicine and medical oncology
WHO report has emphasised need for integration of efforts to maintain QoL in all stages of cancer treatment
- Endorsed by numerous national/professional bodies
- Part of Framework on Palliative Care in Canada
Part of comprehensive cancer treatment
Some studies reflect early, integrated palliative care leads to improvement in QOL and possibly survival
Palliative care for patients who have incurable cancer, whereas supportive care is provided to any patient.
Transitioning Oncology Patients to Palliative Care
Overall:
- May be traumatic for patients as it can imply impending death and triggers fears of helplessness/abandment
- In general, best to introduce early as an important aspect of care alongside efforts to modify natural history
- Recognise from the beginning that treatment goals will evolve from control of disease/maintenance of function, to symptom control
When:
- Early, introduce as optimizing the quality of life
Setting
- Supportive private environment
- Uninterrupted
- With key support people
Evaluate Patient Understanding/Information needs
- Find the balance between info necessary for understanding and ‘assault of truth’
Discuss prognosis
- Be honest
- Use averages, emphasise uniqueness of each patient
- Emphasise limits of predictions
- Commit to non abandoment
- Caution that unexpected events can happen (hope for the best, prepare for the worst)
- Avoid nihilism (don’t say, “nothing more that can be done”)
- Initiate end of life planning
Discuss benefits and risks of anti-tumour therapy
- Always offer palliation without chemo as an option
- Always discuss impact on quality of life
Maintaining hope in patients with incurable disease
- Emphasise what can be done (control of physical symptoms, emotional support, care and dignity, practical support)
- Explore realistic goals
- Discuss issues related to day to day living
Five phases in natural history of cancer
- Diagnostic (Ambulatory or inpatient)
- Curative primary therapy
- Ambulatory palliative therapy
- Sedentary palliative therapy - interactional (home, hospice, LTC, PCU, hospital)
- Sedentary palliative therapy - non-interactional (home, hospice, LTC, PCU, hospital)
Models of care - PC and oncology: Sequential Care
- Patient cared for by oncology service as long as there is benefit in disease-modifying treatment
- Once there is no longer benefit, care transferred to palliative care
- Earlier concurrent care may occur if there is specific interventions required (e.g. pain management)
- EOL care coordinated by palliative care
Advantages:
- Clear delineation of responsibility
- Oncologist focuses on dominant aspects of profession, obligation to provide palliative care/continuity of care through appropriate referral
Implementation
- Requires close cooperation between services
- Good communication to avoid patient feeling of abandonment
- Timely referral
Models of care - PC and oncology: Oncologist-based palliative care
- Oncologist provides both cancer care and palliative care, seeing patient from diagnosis to death
- Emphasises oncologist/patient relationship and ensures continuity/non-abandoment
Advantages:
- Emphasis on continuity of care
Implementation:
- Requires oncologist to have expertise in palliative care and interdisciplinary care
- Access to a palliative care support team
- May require a palliative care specialist for backup in difficult cases
Models of care - PC and oncology: Concurrent model
- Oncologist and palliative medicine specialists collaborate and care jointly for patients
- Relative role determined by prevailing problems
- Evidence suggests improved patient outcomes (survival, QoL)
Advantages
- Duality of advanced cancer care
- Continuity of care
Implementation
- Requires close cooperation and open communication
Minimal requirements for palliative care in a cancer centre (ESMO)
- When receiving active therapy: Routine assessment for presence and severity of physical/psychological symptoms and adequacy of social supports
- If there are inadequately controlled symptoms, evaluate and treat with appropriate urgency
- Cancer centres must provide skilled emergency care of inadequately treated symptoms (physical or psych)
- Ongoing program of supportive and palliative care for patients with advanced cancer who are no longer benefited by anti-tumour therapy
- Incorporate social work and psychological care as part of routine care
- Access to inpatient EOL care, or adequate care in an appropriate hospice or PCU
Criteria for optimal supportive and palliative care in a cancer centre (ESMO)
- Closely integrated oncology/palliative care service
- Philosophy of continuity of care and non-abandonment
- High-level home care with expert back-up and coordination with primary cancer clinicians
- Programmatic support of family members
- Routine assessment for presence and severity of physical/psychological symptoms and adequacy of social supports, with timely and appropriate interventions
- Expert medical and nursing care in the evaluation and relief of pain and other physical symptoms
- Expert care in the evaluation and relief of psychological and existential distress
- Emergency care of inadequately relieved symptoms (physical and psych)
- Facilities and expert care for inpatient symptom stabilization
- Respite care for ambulatory patients who are unable to cope or in cases of caregiver fatigue
- Facilities and expert care for inpatient EOL care and adequate relief of suffering for dying patients
- Participates in basic or clinical research related to QOL for cancer patients
- Involvement in clinician education to improve integration of oncology and palliative care
(Concurrent care, continuity, home care, family support, routine sx assessment and intervention, expertise in symptom management, expertise in psych/existential, emergency care, inpatient care PRN, respite care, inpatient EOL care, QOL research, CPD)
Barriers to coordination between oncology and palliative care
- Different cultures of care
- Oncology focusses on modifying natural history of disease with a view to prolonging life/curing disease
- PC focusses on physical/emotional needs rather than the disease itself - Delays in referral to PC
- Often delayed until patients are severely symptomatic or close to death
- May be due to belief that palliative care is incompatible with ongoing therapy, oncologist attempting to provide palliative care, reluctance by patient/oncologist, lack of resourcing or knowledge, optimism regarding ‘salvage therapy’, fears that palliative will undermine hope or shorten life
- May also be due to overoptimism on the part of the oncologist or patient - Abandonment
- Oncologist may not ensure effective referral or continuity of care for palliative options - Territoriality
- Oncologists may feel that palliative care physicians lack expertise to provide informed advice or will ‘steal’ patients
AEs of Chemotherapy: Alopecia
- Rapidly dividing cells of hair follicles often targeted by chemo
- Paclitaxel and doxorubicin most common causes
- Scalp hair more affected than eyelashes, eyebrows, or body hair
AEs of Chemotherapy: Mucositis
- Damage to mucous membranes, most commonly oral cavity
- Redness, swelling, white exudates, ulceration in severe cases
- Associated with almost all anti-neoplastic agents to some extent
Prevention
- Good dental and oral hygiene
- Daily chlorhexidine mouthwash (efficacy is doubtful)
- Rinses with water/salt/soda solution may he as effective and are not asociated with dental staining
Treatment
- Mouthcare section!
AEs of Chemotherapy: Nail changes
- Taxanes can cause nail abnormalities, including discoloration, nail bed bleeding, and detachment from the nail plate (onycholysis)
- Most nail changes tend to resolve gradually over weeks despite ongoing treatment
AEs of chemotherapy: Hand-foot syndrome
- Common skin reaction with conventional chemotherapy
- Onset begins with painful erythema of the palms, soles, and fingers
- Later becomes edematous, changes colour to violet, then dries and desquamates
- In severe cases, blistering can occur
- Often a dose-limiting side effects
No clear Tx or prevention
