Concurrent Palliative Care Research Articles

Using the New ASCO Clinical Practice Guideline for Palliative Care Concurrent With Oncology Care Using the TEAM Approach.

Palliative care alongside usual oncology care is now recommended by ASCO as the standard of care for any patient with advanced cancer on the basis of multiple randomized trials that show better results with concurrent care than with usual oncology care. Some benefits include better quality of life, better symptom management, reduced anxiety and depression, less caregiver distress, more accordance of care with the wishes of the patient, and less aggressive end-of-life care. Several studies show a survival advantage of several months, and many show considerable cost savings: better care at an affordable cost. However, there are not enough palliative care specialists available, so oncologists must practice exemplary primary palliative care. Protocols used in the clinical trials, similar to those designed for new chemotherapy agents, help oncologists use the TEAM approach of extra time, typically an hour a month spent with the palliative care team; education, especially about prognostic awareness and realistic options, which include formal setting of goals of care and discussion of advance directives; formal assessments for symptoms and for spiritual and psychosocial health; and management by an interdisciplinary team. These are all potentially accomplished by an oncology practice to replicate the services provided by concurrent palliative care.

Integrating Palliative Care Services in Ambulatory Oncology: An Application of the Edmonton Symptom Assessment System.

Research in palliative care demonstrates improvements in overall survival, quality of life, symptom management, and reductions in the cost of care. Despite the American Society of Clinical Oncology recommendation for early concurrent palliative care in patients with advanced cancer and high symptom burden, integrating palliative services is challenging. Our aims were to quantitatively describe the palliative referral rates and symptom burden in a South Texas cancer center and establish a palliative referral system by implementing the Edmonton Symptom Assessment Scale (ESAS). As part of our Plan-Do-Study-Act process, all staff received an educational overview of the ESAS tool and consultation ordering process. The ESAS form was then implemented across five ambulatory oncology clinics to assess symptom burden and changes therein longitudinally. Referral rates and symptom assessment scores were tracked as metrics for quality improvement. On average, one patient per month was referred before implementation of the intervention compared with 10 patients per month after implementation across all clinics. In five sample clinics, 607 patients completed the initial assessment, and 430 follow-up forms were collected over 5 months, resulting in a total of 1,037 scores collected in REDCap. The mean ESAS score for initial patient visits was 20.0 (standard deviation, 18.1), and referred patients had an initial mean score of 39.0 (standard deviation, 19.0). This project highlights the low palliative care consultation rate, high symptom burden of oncology patients, and underuse of services by oncologists despite improvements with the introduction of a symptom assessment form and referral system.

An EPIC electronic decision support tool to identify percentage of patients with stage IV thoracic or gastrointestinal malignancy who would benefit from concurrent palliative care but do not currently receive it.

133 Background: In 2016 ASCO updated its guideline for early integration of palliative care (PC) into standard oncologic care for all “inpatients and outpatients with advanced cancer.” PC has been shown to improve quality of life, align care at the end of life with patient preferences, and reduce health-care utilization. In preparation for the expansion of our palliative care service into ambulatory disease-based practices at Smilow Cancer Hospital at Yale-New Haven, we sought to create a decision support tool (DST) in the EPIC Electronic Health Record (EHR) that would identify patients for PC referral. Methods: This DST identifies patients with a GI or thoracic malignancy who have had an ICD-10 diagnosis of metastatic or stage IV disease, have not had a palliative care visit in the last 6 months, and are not enrolled in hospice. If the patient meets criteria, the DST will remind providers that “this patient meets ASCO and IOM criteria for concurrent palliative care with oncologic care ” and offers a one-click option to place the referral. To understand the volume of patients this DST would refer, we ran it silently in the EHR background from 7/15/16 through 9/1/16. We tracked how many patients were seen in the clinics, how many were eligible, and how many were referred to PC. Results: See table. Conclusions: Our silent BPA indicated that only 5% of patients eligible for a palliative care consult received it at baseline; this matches national data, which suggests that most patients who would benefit from PC do not receive it. This DST has the potential to dramatically improve PC referral rates and increase adherence with ASCO and IOM guidelines. We plan to move the DST into the live clinical EHR in 2017 after the integrated PC clinics are open. We anticipate that once our BPA is activated, we will see a dramatic increase in the number of eligible patients referred to palliative care. [Table: see text]

Older Patients With Acute Myeloid Leukemia: Treatment Challenges and Future Directions.

Even though acute myeloid leukemia (AML) occurs most commonly in adults ≥60 years, the treatment of AML in older patients remains a significant challenge. We reviewed the current literature regarding patient assessment tools, treatment options, and current therapies in clinical trial for patients with AML who are ≥60 years. Our approach to the older patient with AML is evolving with better understanding of the unique disease epidemiology in this population and the development of tools to assess individual patient functional status, including grading systems for comorbidities, geriatric assessment tools, and measurements of frailty. Almost all older patients will benefit from therapy, whether intensive curative therapy, such as allogeneic stem cell transplant that should be considered whenever possible, or low-intensity therapy that should be offered with concurrent palliative care at diagnosis to improve patient survival and quality of life. To achieve the improved survival demonstrated in younger adults, older patients should also be considered for clinical trial enrollment as more studies are being designed to specifically target this unique patient population. Older patients with AML are candidates for and benefit from the entire spectrum of AML therapy, including intense chemotherapy, allogeneic stem cell transplant, and clinical trial participation after thorough patient assessment. Older patients with AML would benefit from increased clinical trial enrollment and early inclusion of palliative medicine.

Does nutrition support have a role in managing cancer cachexia?

Cachexia is a negative prognostic factor in cancer patients. The pathogenesis is related to a variable combination of reduced food intake and metabolic changes. However, whether nutritional support may contribute to effectively prevent and treat cachexia remains a debated issue. Consistent evidence demonstrates that anabolic windows of opportunity occur during the clinical trajectory of cancer patients. Also, the use of specific nutrients, namely omega-3 fatty acids, may enhance the efficacy of nutritional support when tumor-driven inflammatory response is high. Of greater interest, it is now becoming clearer that the use of nutritional support at key time points in the clinical journey of cancer patients (i.e., perioperative period) may extend its clinical benefits beyond those on nutritional status. Nutritional support plays a role in managing cancer cachexia, when it is timely delivered, when it provides adequate amounts of calories and proteins, and when it is part of a concurrent palliative care approach. Specific nutrients, that is, omega-3 fatty acids, may help in those cancer patients with high-inflammatory response, and may also contribute to positively influence long-term clinical outcomes.

Integrating palliative care services in oncology clinics: An application of the Edmonton Symptom Assessment System (ESAS).

168 Background: Research inpalliative care has shown improvements in overall survival, quality of life, symptom management, care satisfaction and reductions in the cost of care. Therefore, the American Society of Clinical Oncology has recommended early concurrent palliative care in patients with advanced cancer and with high symptom burden. Despite this recommendation, integrating palliative services at our NCI-designated cancer center has been challenging. The aims of this project were to quantitatively describe the symptom burden of patients in ambulatory oncology clinics; facilitate the establishment of an effective referral system by detecting discrepancies between symptom burden and referral practices; and improve the integration of palliative care services by implementing the Edmonton Symptom Assessment System (ESAS) tool into 5 of our oncology clinics. Methods: ESAS forms consist of 10 questions assessing patient symptom burden and quality of life. Total scores range from 0 to 100. This tool was distributed to patients at two breast, two gastrointestinal and the thoracic clinics at each visit. The provider reviewed the forms and decided if a palliative care referral was appropriate based on patient responses. The forms as well as referral decisions were entered into REDCap. Over a 5 month period, 607 patients completed the initial assessment and 430 follow up forms were collected, resulting in a total of 1,037 scores collected. Results: The mean ESAS score for all patient visits was 20.7 (SD = 18.7). Only 3.5% (n = 21) of all patients were initially referred to palliative care and 2.6% (n = 11) of patients were referred on follow up visits. Those with an initial referral had an initial mean score of 39.0 (SD = 19.0) and a mean follow up score of 31.9 (SD = 19.5). Conclusions: This project highlights the low palliative care consultation rate and the under-utilization of services by most oncologists at the cancer center despite using the ESAS tool. However, those who received a referral had lower ESAS scores at follow-up. We propose utilizing a trigger that would capture a preset percentage of patients who indicated scores reflective of high symptom burden and distress.

Scalable principles of community-based high-value care for seriously ill individuals: Diamonds in the rough

Early, integrated palliative care has been shown to improve quality of life and reduce utilization in both inpatient and outpatient settings. As health systems shift to risk-based payment structures, palliative care will play an increasing role in improving value of care outside of the hospital. Based on successful models of community-based palliative care, we identify six principles – interdisciplinary team-based care; 24/7 access and responsiveness; concurrent palliative care with disease-directed treatment; targeting services to high-risk patients; integrated medical and social supports; and caregiver support – that are widely implemented because of their impact on improving value for seriously ill individuals.

Clinical significance of palliative care assessment in patients referred for urgent intensive care unit admission: A cohort study

PurposeTo evaluate clinical characteristics of patients with palliative care (PC) and urgent intensive care unit (ICU) referrals in the same hospital admission. MethodsAll urgent ICU referrals at an academic, tertiary hospital, and the co-occurrence and timing of PC assessment were retrieved from a prospectively collected database. ResultsFrom May 2014 to May 2015, 2476 patients were analyzed and 179 (7%) had co-occurrence of PC assessment and urgent ICU referral in the same hospital admission. Hospital mortality was higher (odds ratio, 8.3; 95% confidence interval, 5.4-12.7) and ICU admission was lower (odds ratio, 0.54; 95% confidence interval, 0.40-0.74) in patients with PC assessment, compared with patients without concurrent PC and ICU referrals. Variables associated with PC assessment were older age, diagnosis of cancer, depressed level of consciousness, nonsurgical admission, lower performance status, physician's subjective prognosis of poor outcome, and length of hospitalization before ICU referral. ConclusionIn this cohort of patients with urgent ICU referral, clinical characteristics at the moment of ICU referral were associated with co-occurrence of PC assessment in the same hospital admission. These characteristics might guide the development of instruments to enhance early referral of high-risk patients to PC services.

Cancer care for infants, children and adolescents

The World Health Organization (WHO) defines pediatric palliative care as “the active total cares of the child’s body, mind, and spirit and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease”. There are some unique aspects of caring for children and their families compared to adult patients that create a different set of challenges for care providers. In this chapter we will review some of the specific characteristics of caring for children and their families that must be considered to deliver optimal and effective pediatric palliative care. Ongoing efforts to raise awareness and educate more professionals about palliative care will hopefully dissolve some of the current barriers that hinder access to pediatric palliative care programs. With strong endorsement from the Academy of Pediatrics, it is hoped that all children with serious medical conditions can be offered concurrent palliative care support, focused on quality and quantity of life.

Developing a “Toolkit” for Implementing Early, Concurrent Palliative Care in Community Cancer Centers (S733)

Developing a “Toolkit” for Implementing Early, Concurrent Palliative Care in Community Cancer Centers (S733)

A Tale of Two Cities: Results of the ENABLE CHF-PC Early, Concurrent Palliative Care Heart Failure Feasibility Trial (SA538C)

Objectives Discuss burnout, as identified and described by current hospice and palliative care clinicians, and its implications on the hospice and palliative care discipline. Identify potential ameliorating and protective factors against burnout applicable to the hospice and palliative care clinical workforce. Original Research Background. Clinical palliative care is stressful, with self-reported burnout rates as high as 62% among clinicians. To date, there has been scant qualitative investigation into the causes, ameliorators, and effects of this pervasive phenomenon. Alarming as such statistics may be, quantitative estimates in isolation cannot disentangle the predisposing, situational, and protective factors related to one’s experience of burnout; absent rigorous mixedmethods appraisal of the lived experience of burnout, feasible solutions to address burnout may be out of reach. Research Objectives. To explore sources, implications, and solutions vis-a-vis burnout among hospice and palliative care (HPC) clinicians. Methods. During the 2014 AAHPM/HPNA Annual Assembly, we conducted three semi-structured focus groups on the following topics: personal narratives of burnout, how burnout differs within HPC, and strategies to mitigate burnout. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative technique. Results. We interviewed 20 HPC clinicians (14 physicians, 4 advanced practitioners, 2 social workers). Participants were 65% female; overall, 55% had practiced for 0-5 years, 30% for 6-20 years, and 15% for 21+ years. We observed variability in sources of burnout between clinician types and by practice settings (i.e., hospice or palliative care). Common sources of burnout included: increasing workloads, tensions between non-specialists and HPC specialists, and regulatory issues. Interviewees proposed antiburnout solutions including: promoting the provision of generalist palliative care by colleagues, frequent rotations on-and-off service, and organizational support for self-care modalities. Participants expressed grave concerns about the stability of the HPC workforce and concerns of providing highquality palliative care in light of a distressed, overburdened discipline. Conclusion. Complementing recent survey data, our results illustrate the alarming prevalence, severity and potential ramifications of burnout on the HPC workforce. Additionally concerning is the paucity of protective structures and policies to attenuate burnout.

Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update.

Purpose To provide evidence-based recommendations to update the American Society of Clinical Oncology guideline on systemic therapy for stage IV non–small-cell lung cancer (NSCLC). Methods An Update Committee of the American Society of Clinical Oncology NSCLC Expert Panel based recommendations on a systematic review of randomized controlled trials from January 2007 to February 2014. Results This guideline update reflects changes in evidence since the previous guideline. Recommendations There is no cure for patients with stage IV NSCLC. For patients with performance status (PS) 0 to 1 (and appropriate patient cases with PS 2) and without an EGFR-sensitizing mutation or ALK gene rearrangement, combination cytotoxic chemotherapy is recommended, guided by histology, with early concurrent palliative care. Recommendations for patients in the first-line setting include platinum-doublet therapy for those with PS 0 to 1 (bevacizumab may be added to carboplatin plus paclitaxel if no contraindications); combination or single-agent chemotherapy or palliative care alone for those with PS 2; afatinib, erlotinib, or gefitinib for those with sensitizing EGFR mutations; crizotinib for those with ALK or ROS1 gene rearrangement; and following first-line recommendations or using platinum plus etoposide for those with large-cell neuroendocrine carcinoma. Maintenance therapy includes pemetrexed continuation for patients with stable disease or response to first-line pemetrexed-containing regimens, alternative chemotherapy, or a chemotherapy break. In the second-line setting, recommendations include docetaxel, erlotinib, gefitinib, or pemetrexed for patients with nonsquamous cell carcinoma; docetaxel, erlotinib, or gefitinib for those with squamous cell carcinoma; and chemotherapy or ceritinib for those with ALK rearrangement who experience progression after crizotinib. In the third-line setting, for patients who have not received erlotinib or gefitinib, treatment with erlotinib is recommended. There are insufficient data to recommend routine third-line cytotoxic therapy. Decisions regarding systemic therapy should not be made based on age alone. Additional information can be found at http://www.asco.org/guidelines/nsclc and http://www.asco.org/guidelineswiki. J Clin Oncol 33:3488-3515. © 2015 by American Society of Clinical Oncology

When and why should patients with hematologic malignancies see a palliative care specialist?

Palliative care is a multidisciplinary approach to symptom management, psychosocial support, and assistance in treatment decision-making for patients with serious illness and their families. It emphasizes well-being at any point along the disease trajectory, regardless of prognosis. The term "palliative care" is often incorrectly used as a synonym for end-of-life care, or "hospice care". However, palliative care does not require a terminal diagnosis or proximity to death, a misconception that we will address in this article. Multiple randomized clinical trials demonstrate the many benefits of early integration of palliative care for patients with cancer, including reductions in symptom burden, improvements in quality-of-life, mood, and overall survival, as well as improved caregiver outcomes. Thus, early concurrent palliative care integrated with cancer-directed care has emerged as a standard-of-care practice for patients with cancer. However, patients with hematologic malignancies rarely utilize palliative care services, despite their many unmet palliative care needs, and are much less likely to use palliative care compared to patients with solid tumors. In this article, we will define "palliative care" and address some common misconceptions regarding its role as part of high-quality care for patients with cancer. We will then review the evidence supporting the integration of palliative care into comprehensive cancer care, discuss perceived barriers to palliative care in hematologic malignancies, and suggest opportunities and triggers for earlier and more frequent palliative care referral in this population.

Comment intégrer de manière précoce les soins palliatifs pour les patients atteints de cancer bronchique ?

Early palliative care is not end of life care, which is care for dying and terminally ill patients with cancer. Early palliative care can easier be integrated in supportive care, and is comprehensive patient-centered care, associated with family and caregivers support. Numerous randomized studies about addition of palliative care intervention to standard oncology care provided evidence of benefit about quality of live, overall survival, aggressiveness of end of live care and caregiver burden. One of the most important study with 151 patients with NSL cancer demonstrated better quality of live and survival for patients with palliative care as soon as diagnosis. Since 2011, ASCO established a provisional clinical opinion for concurrent palliative care with standard oncology care. Integrated palliative care organization must be adapted with clinical activity and stakeholders resources in each cancer center but real time screening and address is an essential step. Further studies are needed to address the organization, evaluation tool, guidelines and palliative care training for the best integrated palliative care delivery.

Measuring implementation of early, concurrent palliative care in community settings.

145 Background: ASCO recommends “…combined standard oncology and palliative care…early in the course of illness for any patient with metastatic cancer and/or high symptom burden”. Few settings have implemented this recommendation and rural community cancer centers (CCC) are particularly disadvantaged due to scarce palliative care (PC) resources. The evidenced-based ENABLE (Educate, Nurture, Advise, Before Life Ends) early concurrent PC intervention has demonstrated efficacy and benefit for rural patients and caregivers and we are implementing ENABLE using a virtual learning collaborative funded by the American Cancer Society. Since no PC-specific implementation measures exist, one of our primary efforts has been instrument development. Methods: This Implementation Study includes 4 racially-diverse CCCs: Gibbs Cancer Center, Spartanburg, SC; Mitchell Cancer Institute, Mobile, AL; Birmingham VAMC; and Gyn Oncology/University of Alabama at Birmingham. The project aims are to: 1. Build an interactive research community to assess sites’ institutional structure and PC resources; and 2. Evaluate pre- and post-ENABLE implementation using RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. An expert panel assisted with implementation measure development specific to ENABLE’s essential elements. Instruments include: the General Organizational Index, the RE-AIM Assessment Tool, Oncology Providers Perceptions of Early Concurrent PC, and Implementation Costs. Results: All measures were found to have face and content validity. Feasibility and inter-rater reliability were determined during pilot-testing. Data, (housed in a REDCap database), have been collected using face-to-face interviews and web-based platforms over 2 cycles of pre- and post-implementation site visits. Measurement challenges include: 1. Inconsistent IRB interpretation of implementation science practices; 2. Limited implementation resources (space, staff, and time); and 3. Difficulties with centralized data collection. Conclusions: Valid measures are critical to determine implementation success. We will present implementation measures (Toolkit) and examples of outcome data.

Concordance with the ASCO Provisional Clinical Opinion on the integration of palliative care into standard oncology care in Ontario.

170 Background: In 2012, ASCO released a Provisional Clinical Opinion for patients with stage IV non-small cell lung cancer (NSCLC) and the need for integration of palliative care services concurrent with standard treatment from the time of diagnosis. To understand if this recommendation is being followed in Ontario, provincial administrative data was used to explore concordance. Methods: Various aspects of concordance were considered including: whether and when in the treatment trajectory patients received palliative care, and how much care was received. For Phase 1 of the analysis, a provincial database of outpatient cancer care was used to identify services received within Ontario’s regional cancer centers (RCCs) and select partner hospitals. The Ontario Cancer Registry and Staging databases were used to identify the patient cohort. The cohort included patients diagnosed with stage IV NSCLC between January 1, 2012 and December 31, 2013. Results: Phase 1 results indicate that 41% of patients received palliative and/or psychosocial oncology care at the RCC or partner hospital after diagnosis. Those receiving palliative care first received services an average of 148 days after diagnosis. See Table below for detailed results. Conclusions: A growing body of literature has identified the benefits of concurrent palliative care. Knowing whether these services are being provided for the NSCLC population is a promising start to understanding and improving the delivery of palliative care in Ontario. Initial results suggest that there is a need for quality improvement in this area. Future phases will expand the analysis to include services received in additional settings such as hospitals and community. [Table: see text]

How do they view us? Oncology providers’ perceptions of early/concurrent palliative care.

114 Background: Early integration of palliative care has been increasingly recognized as an important component in the care of cancer patients, including during active anticancer treatment. Yet, palliative and supportive care interventions remain to be well integrated into standard oncology practice. We sought to develop an original survey instrument in order to describe oncology providers’ perceptions of palliative care, particularly when introduced in the early and concurrent setting. Methods: We conducted a systematic review of literature pertaining to perceptions of palliative care and barriers to referral, and extracted survey items where they were found. This pool of questions was narrowed to focus on early/concurrent palliative care, and supplemented with original items. The draft survey was then systematically validated using a standardized scoring system and content-validity approach. Results: Twenty-two studies were reviewed. From an initial pool of fifty items, twenty-nine were selected for the draft survey. The draft was then reviewed by ten oncology providers, who scored each item and provided comments. Conclusions: We have produced a fully validated survey instrument that will be used to characterize oncology providers’ perceptions of early and concurrent palliative care interventions. The validated survey will be administered to oncology clinicians (including nurses, social workers and chaplains) at four academic medical centers at which an early palliative care intervention is currently being implemented. We hope to assess perceptions before and after implementation of the early palliative care intervention.

New ASCO Stage IV Lung Cancer Clinical Practice Guideline Advises Concurrent Palliative Care

New ASCO Stage IV Lung Cancer Clinical Practice Guideline Advises Concurrent Palliative Care

Family caregiver grief and depression outcomes from the ENABLE III randomized controlled trial.

48 Background: Little is known whether early palliative care (PC) support for family caregivers (FCGs) impacts grief and depression after care recipients die. We conducted a randomized controlled trial (RCT) of a nurse-led, phone-based concurrent PC intervention for FCGs delivered at the time of care recipients’ advanced cancer diagnosis (early group) or 12 weeks later (delayed group). We hypothesized that grief and depression scores would be lower for early compared to delayed group FCGs. Methods: Early vs. delayed RCT (10/2010-9/2013) of 123 FCGs of community dwelling persons with advanced cancer in a rural, New Hampshire NCI-designated comprehensive cancer center and affiliated outreach clinics and a Vermont VA medical center receiving a multicomponent intervention (ENABLE [Educate, Nurture, Advise, Before Life Ends]) consisting of 3 weekly sessions, monthly follow-up, and a bereavement call. FCGs of persons dying during the study period completed the Center for Epidemiological Study-Depression scale (CESD) and the Prigerson Inventory of Complicated Grief-Short Form (PG13) 8-12 weeks after care recipients’ deaths. Generalized estimating equations were used to compute group means, standard deviations, and between-group effect size differences. Results: For care recipients who died (n = 70), 44 FCGs (early: n = 19; delayed: n = 25) completed after-death questionnaires. Mean depression scores (CESD) for the early group was 14.6 (SD = 10.7) and for the delayed group was 17.6 (SD = 11.8). Mean grief scores (PG13) for the early group was 22.7 (SD = 4.9) and for the delayed group was 24.9 (SD = 6.9). Between-group effect size differences were not statistically significant (CESD: d = -.27, p = .38; PG13: d = -.36, p = .24). Conclusions: Though statistically insignificant, the magnitude of the observed between-group differences for depression was small and for grief was medium. Considering the small sample size and the delayed group’s mean depression score surpassing the clinical cutoff (CESD score > 16), the clinical relevance of these findings cannot be ruled out. Future upstream FCG PC interventions initiated long before end of life should continue to examine intervention effects on FCG after-death outcomes. Clinical trial information: NCT01245621.

Medicare Care Choices Model Enables Concurrent Palliative and Curative Care

EDITOR'S ABSTRACTOn July 20, 2015, the federal Centers for Medicare & Medicaid Services (CMS) announced hospices that have been selected to participate in the Medicare Care Choices Model. Fewer than half of the Medicare beneficiaries use hospice care for which they are eligible. Current Medicare regulations preclude concurrent palliative and curative care. Under the Medicare Choices Model, dually eligible Medicare beneficiaries may elect to receive supportive care services typically provided by hospice while continuing to receive curative services. This report describes how CMS has expanded the model from an originally anticipated 30 Medicare-certified hospices to over 140 Medicare-certified hospices and extended the duration of the model from 3 to 5 years. Medicare-certified hospice programs that will participate in the model are listed.