Transcript When should a Service refer to Specialist

Referrals to
Palliative Care Services
Medical Oncology perspective
Kavi Capildeo MBBS FRCP(Edin) DM
SMO, Eastern Regional Health Authority
Cancer as a cause of mortality
Cancer: W.H.O. estimates
– ≈ 40% preventable- ∴ ≈ 60% are not
– ≈ 40% curable- ∴ ≈ 60% are not
Trinidad and Tobago
– 3rd leading cause of death
(after cardiovascular disease and diabetes)
Death from cancer generally not
sudden/instantaneous
http://www.who.int/cancer/WHA_cancer_presentation_final.pdf Accessed Oct 16, 201140%
www.cso.gov.tt
Cancer mortality in Trinidad and
Tobago
Jan 1997- Dec 2006: 12616 deaths
– Male: 6876
Female: 5740
Top 5 causes of cancer death
– Prostate
– Breast
– Colorectal
– Bronchus and Lung
– Leukemia
Elizabeth Quamina Cancer Registry
20%
11%
10%
8%
6%
Palliative care - trajectories
Function
High
Function
High
Death
Low
Time
Erratic decline eg
organ failure
Death
Low
Time
Function
High
Death
Source:
NHS
Scotland
Low
Time
Oncology clients and palliative care
What palliative care needs can oncologist meet?
When should client be referred for palliative care?
– What palliative care services exist in T&T?
– Adequate? If not, how to fix system?
When can patients receiving palliative care
benefit from intervention by oncologists?
Oncology services in T&T
National Radiotherapy Centre
Regional clinics: ERHA, SWRHA, Tobago
2 private centres
Radiation and medical oncologists
Oncology nurses
Social workers
Pharmacists
Palliative care within Oncology Clinics
Evaluation of pain and other symptoms
Pain medications, other drug therapies
Psychosocial support: Medical Social Worker
Oncologic intervention with palliative intent
– Radiation
– Chemotherapy
– Endocrine therapy
– Targeted therapies
– Palliative surgery
Palliative care in oncology
clinic setting: limitations
Limited community outreach
No care facility for terminally ill in MoH service
Staff have other duties
– Radiation planning/delivery, chemo etc
– No staff exclusively assigned to
palliative/supportive care
Patient/family may not perceive clinic as
source of supportive care (or even interested)
– “doctors can’t do anything more”
No safety net?
Fall from clinic
system→ a hard
landing for the client?
? Pressure to maintain
status quo with
continued efforts at
chemo/RT
Palliative care services in TT
3 hospices
– 1 exclusively for cancer, 1 for HIV/AIDS
– All NGO based
– All in POS
Community-based, nurse-led service
– St. Andrew/St. David only
GPs with experience in palliative care
– Private sector
– ? <10
INCB and Trinidad
United Nations agency
Regulates international sale of narcotic
drugs
T&T- severe limits
Chronic shortages
300000
250000
200000
2011 drug
allocations in
grams
(expressed as
quantity per
million
population)
150000
100000
Canada g
per million
pop
50000
Trinidad g
per million
0
http://www.incb.org/pdf/technicalreports/narcoticdrugs/2010/NAR_2010_EFS_Part
3.pdf , accessed Oct 15 2011
Quantities per 1 million population
calculated using 2009 World Bank
population estimates
Why?
Palliative care in TT
Limitations and challenges
Community-based, public-sector services
– Absent in most areas
– MoH support required
Hospice facilities
Outpatient clinics
Personnel
Training and education
Equipment and drugs
Public awareness
Oncology and Palliative Care
Both multidisciplinary, client centred
Overlapping objectives
– Quality of life and death
– Symptom relief
– Supportive care
Complementary roles
Kaplan–Meier Estimates of Survival According to Study
Group.
Randomized trial of
early palliative care
referral vs standard
care in pts with
metastatic NSCLC
•Higher QOL scores
•Improved mood
•Improved survival
•Less aggressive endof-life care
Temel JS et al. N Engl J Med 2010;363:733-742.
Appropriate referrals
Oncology staff, clients, families
– Awareness of available services
– Timely referral
– Aware of referral pathways/protocols
Palliative care services
– Refer when appropriate for intervention to
control symptoms
Palliative RT: bone pain, SVCO, etc
Systemic treatments
DEFINING PALLIATIVE CARE
World Health Organisation
Approach to care that ↑ QoL of patients/
families with problems associated with life
threatening illness
Prevention and relief of suffering
– early identification and impeccable assessment
and treatment :
pain
other problems
– physical
– psychological
– spiritual
Palliative care- whose
responsibility?
Palliative care is the responsibility of all
health and social care professionals
delivering care
(NICE, 2004)
Specialist palliative care services
When should a Service refer to
Specialist Palliative Care?
“When they lack the skills, confidence or expertise to cope
adequately with a problem…”
• Uncontrolled/complicated symptoms
• Uncontrolled anxiety or depression
• Complex emotional needs involving children, family or carers
• Complex issues relating to physical and human environment (i.e
home, finances etc)
• Unresolved spiritual issues around self worth, loss of meaning and
hope (may include euthanasia issues)
Bradford & Airedale
Managed Clinical Network
Palliative / End of Life Care
Education Programme
Specialist Palliative Care
Provision
Bradford &
Airedale
Managed Clinical
Network
Palliative / End of
Life Care
Education
Programme
21
Three triggers for Supportive/
Palliative Care
1.
2.
3.
The surprise question:
‘Would you be surprised if this patient were to die
in the next 6-12 months?’
Choice:
The patient with advanced disease makes a choice for
comfort care
Clinical indicators:
Specific to each of the three main end of life groups cancer, organ failure, elderly frail/dementia
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Supportive and Palliative Care
Indicators tool
(1) Ask
Does this patient have an advanced long
term condition, a new diagnosis of a
progressive life limiting illness, or both?
Would you be surprised if this patient
died in the next 6-12 months?
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Supportive and Palliative Care
Indicators Tool
(2) Look for one or more general clinical
indicators
Performance status poor or deteriorating
Progressive weight loss (>10%) over past
6 months
2 or more unplanned admissions in last 6
months
Patient is in a nursing /care home, or
needs more care at home
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Cancer- palliative care
indicators
Performance status deteriorating due to
metastatic cancer and/or comorbidities
Persistent symptoms despite optimal
palliative oncology treatment
Too frail for oncology treatment
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Clinical indicators for terminal care
Q1. Could this patient be in the last days
of life?
Confined to bed/chair or unable to self
care
Difficulty taking oral fluids or not tolerating
artificial feeding/hydration
No longer able to take oral medication
Increasingly drowsy
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Clinical indicators for terminal care
Q2. Was this patient’s condition
expected to deteriorate in this way?
Q3. Is further life-prolonging treatment
inappropriate?
Q4. Have potentially reversible causes
of deterioration been excluded?
Holmes, S. Practicalities of palliative care.
www.bradfordvts.co.uk Accessed Oct 16, 2011
Summary
Palliative care for patients with cancer
– Responsibility of all involved HCWs
– Teamworking to improve quality of life, endof-life care
– Appropriate and timely referral to specialist
palliative care services (where available)
– Gaps in system need to be addressed
Family/
Carers
Oncology
team
Patient
Social
work,
community
services
Palliative
care team