Using the Morbidity and Mortality Conference Model to Explore and Improve Community-Based Oncology Care (Video Program)Hospice in end-of-life care and access to palliative care services for oncologists in community practice
5:26 minutes.
TRANSCRIPTION:
DR LOVE: How do people react when you bring up the issue of hospice? DR RODRIGUEZ: I don’t mention the word hospice. I kind of talk about palliative care as a concept where, “There comes a time where you will be best served by supportive care, and chemotherapy is going to harm you. And you’re tired and sick, and coming here all the time is not helping you, and we can help you at home.” I try to frame it like that, because I find when I say “hospice,” everybody shuts down. DR LOVE: Any comment on your own experience of — I’m kind of struck by the emotional reaction at the word hospice. Is that what your experience is? DR PICTON: Yes. Usually, I did — I do, in that first meeting, say, “You have metastatic lung cancer. And the goal of the treatment will be palliative.” But how many patients hear? They don’t hear. “You never told me that.” Sometimes, for them, the word hospice means giving up. DR LOVE: Any thoughts about this? And also, lung cancer has a lead role: Jennifer Temel is in lung cancer at MGH, has looked at palliative care — not hospice care, palliative care — early, at diagnosis. Any thoughts about that work and this issue of the psychologic impact of hospice and palliative care? DR WAKELEE: Well, I think palliative care is focused on symptom management, on hearing what’s going on with the patient, focusing on pain, focusing on nausea, focusing — the general well-being. And as oncologists, we always feel like we’re doing a really good job of that. With that particular trial, the patients who were randomized to get the palliative care were actually being seen a lot more often and really having their cares addressed, and by people who do have additional training in symptom management. And so it is important to be very mindful of that and for patients, especially, who are having a lot of symptoms, bringing in another team, a palliative care-focused team, can be great. I have the luxury of having a really fabulous palliative care group that I can co-manage my patients with. And so we do that, especially for someone who is struggling at all. DR LOVE: But you kind of pushed it, or you emphasized more the symptom management, and yet the people that I’ve talked to who were involved with that, a lot of these patients were not symptomatic in that trial. And, of course, the trial was just — whatever, but the idea being that they were able to provide benefit even to asymptomatic patients, which is kind of hard to get a fix on. You ask the people who were involved, and they say, “Well, maybe they dealt with their anxieties better. They helped them cope more.” I wonder whether or not patients who get that kind of attention maybe have a greater drive, if you help them cope, maybe they want to live longer. I don't know. DR WAKELEE: Yes. I think it’s hard to tease out exactly. And I think it’s about, again, helping patients live. And we’ve talked about that early on. It’s sort of, how do you help patients live the best they can? And dealing with symptoms is important. Dealing with anxiety is important. Not squashing hope is important. The idea of hospice — I get that same reaction, usually, and so I do a very similar approach, where never with the, or almost never with the first visit, unless someone’s really, really sick to begin with, but kind of waiting and saying, “Well, we’ve got this option and this one, and at some point we might get to a point where the risks of the treatment outweigh the benefits of the treatment.” That’s the way I usually phrase it, and when that comes, we think more about hospice and symptom management. And so trying to bring it in a little bit before it’s right there, and then referring back to that discussion because people usually do block it out, as you said. DR LOVE: So I’m curious, Maria, how the concept of palliative care plays out where you are. Do you have palliative care specialists available to you that you utilize? DR PICTON: We do have a palliative care service available, but not as outpatient. You have to be in the hospital to be able to meet with this team. And I have been pushing to have them open an outpatient clinic because I would like to have my patients that have a lot of symptoms go visit them and have them participate in their care. DR LOVE: Any thoughts? How does palliative care play out where you are? And any thoughts about what you just heard? DR RODRIGUEZ: So the palliative care part, it’s a work in progress. I feel that insurances haven’t really owned the palliative care arena. For example, we have a palliative care service like that in the hospital where they get covered, and they see patients. But if you’re outpatient, then you have to kind of break it into a pain management, and if they don’t take their insurance they won’t see them. So it gets very challenging. And I find that we do the palliative care. Like at some point I don’t have to refer them out because I will be doing most of it. But one thing that has been very positive with the whole national discussion about end of life is that the new residents and the new fellows are having these discussions in the hospital with patients. And something that’s a little bit out of place, like you admit a patient and then someone calls a palliative care consult. And I’m like, “What happened here?” because I’m the one who knows this patient. And then I realize, “This is okay. This is another part of the team, someone who’s seeing this case. Maybe I’m too involved in this case.” And someone is seeing this case and sees that this patient is not doing well and should have this discussion now. So I think it took me some time, but now I’m very open to those consults coming from other parts of the team. But most of them are happening in the inpatient setting. |