Maine Cancer Consortium – Palliative Care S Steven L. D’Amato BSP, BCOP

Maine Cancer Consortium –
Palliative Care
Steven L. D’Amato BSP, BCOP
Executive Director, Maine Center for Cancer Medicine
S Present system objectives and goals for an advanced
palliative care program
S Discuss quality outcomes and measures that can be derived
from an integrated system
Palliative Care
S Definition
S Palliative care is both a philosophy of care and an organized,
highly structured system for delivering care to persons with lifethreatening or debilitating illness.
S Palliative care is patient and family-centered care that focuses
upon effective management of pain and other distressing
symptoms, while incorporating psychosocial and spiritual care
according to patient/family needs, values, beliefs, and
Palliative Care
S Goal
S The goal of palliative care is to prevent and relieve suffering
and to support the best possible quality of life for patients and
their families, regardless of the stage of disease and the need
for other therapies.
S Palliative care can be delivered concurrently with lifeprolonging care or as the main focus of care.
Palliative Care Standards (1/2)
S Institutions should develop a process that ensures all
patients have access to palliative care services from the
initial visit.
S All cancer patients should be screened for palliative care
needs at their initial visit, at appropriate intervals, and as
clinically indicated
S Patients and families should be informed that palliative care
is an integral part of their comprehensive cancer care.
Palliative Care Standards (2/2)
S Educational programs should be provided to all healthcare
professionals and trainees so that they can develop effective palliative
care knowledge, skills, and attitudes.
S Skilled, palliative care specialists and interdisciplinary, palliative care
teams should be readily available to provide consultative or direct care
to patients/families who request or require their expertise.
S Clinical health outcomes measurement should include palliative care
S Quality of palliative care should be monitored by institutional quality
improvement programs.
NCCN Guidelines Version 2.2011 Palliative Care
Palliative Care Evidence
S There have been two recent studies published, one by Bezjak
and another by Temel, that demonstrate that individuals
diagnosed with Stage IV lung cancer treated with
chemotherapy and an organized program of palliative care
and symptom control achieved longer survivals than those
treated with chemotherapy alone and no intervention from a
palliative care consultant.
Bezjak A et al. J Clin Oncology 2006;24:3831-7.
Temel JS et al. NEJM 2010;363:733-82.
Palliative Care Reduces Expenditures
Mean direct costs per day for palliative care patients who were discharged alive (A) or died (B)
before and after palliative care consultation
Morrison, R. S. et al. Arch Intern Med 2008;168:1783-1790.
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Palliative Oncology
S More than 1.5 million people diagnosed with cancer in 2010
S 0.5 million died of the disease
S Patients are referred too late to derive the benefits from
comprehensive palliative care
S Administration of chemotherapy late in the course of
cancer care, including the last days of life is becoming more
An Organized Palliative Care Program Will Be A Critical
Component to the Development of an Oncology Centered
Patient Medical Home
S Optimize patient outcomes in terms of prolonging survival and
patient QOL
S Optimize patient outcomes in terms of preparing them in
appropriate time frame for the eventual failure of modern
oncolytics to control their disease
S Optimize informed delivery of oncolytics to patients based upon
true measurements of treatment successes
S Partner with the patients to make ethical decisions regarding the
use of medical technology/pharmaceuticals as disease progresses
The Five Questions
S Who do you want to make health care decisions for you
when you can not make them?
S What kind of medical treatment do you want or not want?
S How comfortable do you want to be?
S How do you want people to treat you?
S What do you want your loved ones to know?
The Big Six
Intent of therapy
Adverse event grade
Disease status
Patient status
Line of therapy
Palliative Care at MMC
S Inpatient program – consulted for management of pain and
other symptoms, emotional distress, end of life consultation
regarding DNR and choices, site of hospice services (e.g.
home vs Gosnell House)
S Outpatient program – intended to partner with physicians
and other clinicians to co-manage patients with terminal
illness in an outpatient setting
MMC Outpatient Palliative Care Clinic has Challenges with
Broad Integration into the Management of the Oncology
Patient in the Outpatient Setting
S Meets 1 day per week (may be changing)
S Introduces a new “team” of care providers to a patient that
already closely identifies with their primary medical oncologist
S Possible confusion regarding who is managing what problem
S Who does the patient call after hours when there is a problem
with medication
S Management of the shear volume of terminally ill patients
MCCM is in the Process of Developing an
Outpatient Palliative Care Program (1/2)
S A dedicated physician has been hired with the following
S Teach all physicians, RNs, and midlevel providers about
effective palliative care and keep the entire practice updated on
the newest developments in this field
S Maintain and update all QOPI indicators on palliative care at
all sites
S Coordinate outpatient care with each hospital’s inpatient
palliative care program
MCCM is in the Process of Developing an
Outpatient Palliative Care Program (2/2)
S A dedicated physician has been hired with the following
S Provide palliative care consultations to MCCM patients
S Work in conjunction with the patient’s MCCM team to execute
and optimize the plan of care
S Develop tools in OncoEMR (Altos) to effectively measure
outcomes of palliative care intervention
Vision of an Integrated Palliative Care
S MCCM/MMCCI integration of palliative care efforts
S Education of providers
S Develop tools for clinicians, patients, and families
S Develop a systems-based approach to care
S Measure quality indicators
S Improve primary care knowledge, skills, and practice behavior
S Palliative care documentation and integration of electronic
S Coordination with hospice programs
Eight Domains of Palliative Care
(NCP and NQF)
Structure and processes of care
Physical aspects of care
Psychosocial and psychiatric aspects of care
Social aspects of care
Spiritual, religious, and existential aspects of care
Cultural aspects of care
Care of the imminently dying patient
Ethical and legal aspects of care
Palliative Care Efforts and
Alignment with NCCP Goals
S MMCCI commits to continue its palliative care initiatives
aimed at increased integration into the cancer program,
including referrals to hospice.
S Through these efforts we aim to improve one or more
categories on the NCCCP Palliative Care Matrix
Assessment Tool by at least one Level during year 3 of
QOPI 2012
S MCCM/NCCCP QOPI Certification for 2012
S Interim spring 2012 report
S QOPI Certification Overall Quality Score Required: 72.62%
S MCCM QOPI Score: 85.33%
S Minimum Adjuvant Measure Score needed: 80%
S MCCM Adjuvant Measure Score: 93.88%
QOPI EOL Measures (1/2)
S Pain assessment
S Pain Intensity
S Plan of care for moderate/severe pain
S Pain addressed appropriately
S Dyspnea assessed
QOPI EOL Measures (2/2)
S Dyspnea addressed and addressed appropriately
S Hospice enrollment (7 different measures)
S Hospice enrollment or palliative care referral services
S Chemotherapy administered within the last 2 weeks of life
Integration Leads to Better Care
S Five areas where integration is critical to optimize
S Symptom management
S Transitioning from disease-focused care to palliative care
S Discussing goals of care and advance care planning
S Community care
S Psychosocial support for patients and families
S Palliative care is a critical component of overall cancer care
S Education and development of system wide resources is
necessary for an effective program
S Implementation of a comprehensive palliative care program
will result in better patient outcomes, improved quality of
life, and reduce healthcare expenditures.