Palliative Care for Cancer Patients

Dr. Lawrence Solomon and Leslie Blatt, APRN,
Palliative Care for Cancer Patients
August 8, 2010Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Dr. Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy
Director and Chief of Medical Oncology at Yale Cancer Center and
Dr. Foss is a Professor of Medical Oncology and Dermatology
specializing in the treatment of lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu and
the phone number is 1888-234-4YCC.  This evening Francine is
joined by Dr. Lawrence Solomon, Associate Professor of Medicine and
Director of the Yale-New Haven Hospital Adult Palliative Care
Service, and Leslie Blatt, APRN who is the Clinical Director of the
program.  Here is Francine Foss.Foss
Let's start off by talking about a very basic question, what is
palliative care and when is it typically recommended for patients
with cancer?Solomon
Palliative care is a relatively new medical specialty, and it is
directed towards improving the quality of life of patients and
their families who are faced with a life threatening illness. 
Its goal is to identify and treat both symptoms and concerns
whether they be physical such as pain, emotional, social, or
spiritual. To do this it requires the skills of a multidisciplinary
team consisting of physicians, nurses, social workers and pastoral
care representatives, among others.  Historically, palliative
care was focused on patients with incurable forms of cancer, but
this specialty has a role in assisting patients with many other
serious illnesses such as those associated with severe impairment
of heart, lung, kidney, liver, or neurologic function.Foss
That is really an important point Larry, because most of us think
about palliative care only in the setting of caner.Solomon
This has been a real shift over the last 5 to 10 years to include
these other disorders as well.Foss
Let me ask both of you how you got involved in palliative care.
 Could we start with you Leslie?Blatt
 I feel I have been doing pieces of palliative care throughout my
nursing career.  I initially worked in the intensive care unit
and I did some hospice nursing for a while and then as a
psychiatric liaison nurse. I think for me palliative care combines
all my areas of interest, which is acute medicine but also focusing
on how that illness impacts the patient and their family because I
do not think you can really separate the disease from what else is
going on in the patient's life.  As Larry was saying earlier,
it encompasses all the things that make up a patient.  So
that's how I got interested.Foss
Leslie, you are an APRN, which is an advanced practice nurse, could
you just tell our audience how that differs from an RN?2:54 into mp3 file 
http://yalecancercenter.org/podcast/aug0810-cancer-answers-solomon-blatt.mp3Blatt
 I have gone back to school and I have gotten my masters degree and
that allows me to have prescriptive authority, so I am able to
write prescriptions and medications for patients.Foss
Larry, how did you get involved in palliative care?Solomon
For me it was somewhat a matter of serendipity related to time and
place.  I actually started my career in this area in the 1970s
in cancer treatment and about that same time is when awareness of
the many needs of patients with incurable illnesses was coming to
the forefront in medical communities.  It is also the time
that Florence Wald established the first hospice in the United
States right in New Haven, Connecticut where I was working. 
Later, I had the opportunity to work at that institution and was
just amazed at the impact good symptom management by an
interdisciplinary team could have on a patient and their family,
and this experience ultimately lead to my current work in
palliative care.Foss
You mentioned hospice, could you just clarify for our audience who
may not familiar with that term, what is hospice?Solomon
Hospice is involved with the care of patients towards the ends of
life when treatments that try to either cure or control an illness
are no longer effective.  That was actually a starting point
for approaches to keeping patients comfortable and helping with all
phases of their life in the face of such illness, and eventually
extended into palliative care.Foss
I did not know that the first hospice was here Connecticut.Solomon
Absolutely, Florence Wald was the main driver of that movement with
some colleagues here following the leadership of Cicely Saunders in
England and bringing that program here.Foss
Larry, could you talk a little bit about the term 'palliative care'
and tell us when palliative care was first introduced in the
medical world?Solomon
It came as an off shoot, if you will, or rather an extension of
hospice care.  Hospice care in the 1960s started recognizing
the patient's family needs towards the end-of-life.  These
program approaches to improve quality of life grew and became more
and more effective and it became recognized that these approaches,
and the support for the family, was valuable not just at the end of
life, but throughout the course of the significant illness, and
this concept lead to palliative care becoming recognized as an
approach about a decade later and just four years ago it became a
formal specialty here in the U.S.Foss
Physicians now can be so called board certified in palliative
care?5:47 into mp3 file 
http://yalecancercenter.org/podcast/aug0810-cancer-answers-solomon-blatt.mp3
 Solomon  Yes.Foss
And those palliative care physicians are they primarily
oncologists, or do they represent all different subspecialties?Solomon
Actually, they are spread all over the clinical map.  A lot of
them came from oncology initially, but a lot come directly to this
specialty from a variety of places as diverse as generalized
internal medicine, radiation therapy, radiology, and emergency room
medicine. All those are sources of potential palliative care
physicians.Foss
As a palliative care physician, do you consider yourself a general
internist; I mean you cover all different areas of involvement for
that patient?Solomon
One of the greatest challenges of palliative care is to keep your
mind open as to what can be going on and impacting on a patient's
life, and to that end, I do think of myself as an internist to look
for opportunities to improve the wellbeing of patients by
understanding that other things may be going on over and above the
underlying illness.Foss
Leslie, you also mentioned that your background in psychiatry and
other areas has contributed significantly to your ability to work
with this group of patients.Blatt
 Yes, I think that one of the things that we both do pretty
consistently is just listen to people and help them through
difficult transitions that they go through, and so communication is
a really important part of what we do.Foss
Could we talk a little bit about the differences between
end-of-life care and palliative care?Solomon
Those distinctions are very, very important.  As I mentioned,
hospice became an area of care that was focused towards the end of
life.  This was a time when treatments directed to either
curing or controlling an illness were no longer effective.  In
contrast, palliative care begins early in the course of a life
threatening illness.  It works concurrently with all efforts
possible to cure or control the disease.Foss
So palliative care doesn't necessarily mean that a patient isn't
undergoing treatment.Solomon
Absolutely right, and that treatment can even eventually result in
cure.Foss
In your mind then, do you distinguish between end-of-life and
palliative when you see an individual patient? Is there a marker
between those two or is it a transition?8:16 into mp3 file 
http://yalecancercenter.org/podcast/aug0810-cancer-answers-solomon-blatt.mp3Solomon      
 Definitely the latter.  This is part of the continuum which
may end either successfully with cure of the disease, or with the
patient's death later on, but nonetheless the same techniques
remain to improve quality of life throughout the course of the
illness.Blatt
 It takes the best of the hospice model, which is really focusing
on the patient and their family and brings it much more forward in
the course of the care, and if you think about it, if the disease
does not just affect the patient, but their whole life, to have the
recourses available to help people and their family deal with the
changes that occur with any chronic or life threatening illness is
really important, and I think that is what palliative care
brings.Foss
Can you tell us a little bit about how a palliative care program is
put together, the program at Yale- New Haven?  How long has it
been in operation and what are your roles in the program?Blatt
 We have been in existence approximately going on three years and
we continue to grow.  We average about 40 to 50 new consults a
month and I have a daily census of about 12 to 15 patients. 
We are really excited about the growth of our program and that we
receive consults from all over the hospital, although at this
moment the majority of our patients do have a cancer
diagnosis.  The attending physician invites us to come in and
often consults are at the prompting of the nurses or the social
workers or Chaplins on the unit.  This is often how we get our
consults.  Our role is that we usually see patients together
for the first consult and the reason for that is partly because we
both hear the information from a different perspective as well as
trying to limit the amount of time somebody has to tell their
story, because if you have ever been in a hospital, you know that
there are a ton of people that come in and ask people to repeat the
same information over and over again.  After that, I am
usually doing the follow-ups and if there are any questions or
concerns we discuss the cases pretty much on a daily basis.Foss
If a patient were to initiate a consult, they could do that by
talking to their nurse, for instance, or their physician if they
wanted to talk to a palliative care doctor.Blatt
 Yes, usually we do like the attending physician to invite us into
the case and most of the time when patients have asked for our
services, everyone usually complies. It is also important to note
that palliative care programs also lead to patient's
satisfaction.  So that can also look good for that hospital,
the attending physician, and us as well.Foss
Now it gets back to a basic question, which is, if a patient is in
the hospital for particularly a prolonged period of time, how does
a patient actually find out that palliative care is even out
there?Solomon
There are many ways that they may hear about our services; one is
of course from the clinician themselves, secondly, palliative care
is very much in the new these days about these options in11:34 into mp3 file 
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 their care and they may hear about it from family members and
friends.  They may hear about it from other healthcare workers
as well.Foss
Are there conversations within the hospital, interdisciplinary
conversations, where palliative care gets brought up say in the
management of a patient?Blatt
 It does happen and oftentimes it happens on the daily rounds on an
individual team, and I know the nurses and social workers are well
acquainted with what our services can offer and oftentimes it
starts with anybody that is having a symptom that needs additional
management and that's often how we get involved initially into the
consult.Foss
Can you tell us a little bit about what the major issues are that
patients are facing financially, with family, etc.  What are
the key issues for patients nowadays?Blatt
 It is varied, as our patients are varied, so are their issues, but
oftentimes it involves a lot about transition points in their
care.  Frequently, it is related to loss.  This happens
right along through any chronic illness as well as the other
transition phases that may occur. Oftentimes when treatment goals
need to change or psychological or spiritual issues may also impact
that.  I think it is a combination of things, not just the
physical issues, not just transition points, but also how that
illness has impacted them in their daily life, how it changes their
roles in the world, and in their family.Foss
With the current economic situation, have you seen more patients
who have financial concerns as well that impact them?Blatt
 I think financial concerns are always there and yes, I would have
to say that is true because the economic times make it even more
difficult then it has been previously.Foss
I would like to talk a little bit more about what you are doing
with specific patients and specific diseases when we come back. We
are going to take a break now for a medical minute.  Please
stay tuned to learn more about palliative care with my guests Dr.
Lawrence Solomon and Leslie Blatt.14:34 into mp3 file 
http://yalecancercenter.org/podcast/aug0810-cancer-answers-solomon-blatt.mp3Foss
Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss and my guests tonight are Dr. Lawrence Solomon and
Leslie Blatt who join me to talk about palliative care.  We
talked a little bit about what palliative care is and I would like
to ask a question which is, how has palliative care changed over
the last couple of years?Solomon
That is a very important question Francine because, in fact,
understanding the role of palliative care by both patients and
physicians is still often limited.  Palliative care continues
to be equated with hospice and end-of-life care and it is still
frequently considered to be a last resort, even though palliative
care can be very much a part of a therapeutic program aiming to
cure or control an illness.  In addition, many patients and
physicians continue to believe that in hospice care and palliative
care, the use of morphine and related medications actually shortens
survival and produces serious side effects; this is simply not the
case. In fact, a recent study from Harvard, presented just this
month at the American Society of Clinical Oncology Meeting actually
showed that palliative care given to patients within curable lung
cancer not only improved the quality of life, but actually
increased survival as well.Foss
That gets us to another issue, for many cancer patients one of the
major things that they grapple with in addition to their diagnosis
are all the side effects and the fatigue and the emotional stress
related to the treatment itself.  Do you actually help
patients to manage this?Solomon
Yes, we are involved with that as well.  Most oncologists are
very aware of these frequent side effects that are absolutely
devastating and frightening to patients as they anticipate their
treatment.  These include nausea, diarrhea, and loss of
appetite, weakness, and increase in pain. All of these impact on
the emotional well being of both the patient and their
family.  The oncologist can anticipate many of these and does
control them very well with medications both before and during the
administration of chemotherapy.  On other occasions, we can be
helpful in identifying additional factors that can contribute to
these symptoms and provide new therapeutic approaches to help
control them as well.Foss
Do you also help patients in terms of integration of other
modalities, say if they need dietary advice or exercise or other
quality of life issues?17:34 into mp3 file 
http://yalecancercenter.org/podcast/aug0810-cancer-answers-solomon-blatt.mp3Solomon  
    
 Absolutely, and I think we should talk about the interdisciplinary
team. I mentioned just a small portion of that, but involvement of
a dietician, physical therapist, and a pharmacist to help with more
usable forms of mediation are all important to optimizing what can
be done for a patient.Foss
Can you describe what a typical meeting or session with a patient
is like?Blatt
 There is actually not a typical session or meeting, but what we
try to do is give a comprehensive assessment that includes not only
the physical, but also the psychological and spiritual realm and
see what we can do to help improve the patient and their family's
quality of life.  We try to get a sense of who they are and
what their goals are so that we know how best we can help. We
actually take our lead from them much of the time.Foss
Do you oftentimes meet with family at the same time that you meet
with the patient? Or do you have individual meetings with family at
separate times, how do you work that in?Blatt
 We like to meet with the families and if they are in the room when
we are doing our initial assessment, we certainly invite them to
stay if it is okay with the patient, and most of the time it
is.  If we do not meet them on our initial visit, at some
point during the person's hospital stay we will meet with them and
sit down and talk with the patient and the family as a whole and if
the family wants to see us separately we do that as well.Foss
Another thing for patients to know is that you actually bridge the
inpatient and the outpatient, your practice is in both arenas.Solomon
Absolutely, we are seeing patients right now a half day a week in
clinic.  Many of these are follow-ups of patients we have met
for the first time in the hospital, but also we are getting to meet
many patients earlier in the course of their disease through the
outpatient clinic.Foss
Why is it so important for physicians to be aware of the benefits
of palliative care?Solomon
In this day-and-age, physician training is often very specialized
to be on the top of what you do and provide quality of care in all
areas of medicine.  You have to be aware of a body of
knowledge that is expanding at a very great rate and physicians are
also facing enormous demands on their time.  In palliative
care, we can compliment what physicians are doing for the care of
their patient's by providing additional time to identify and
address patient's family concerns and providing additional
expertise in symptom management.Foss
I know that you also work extensively with other staff in the
hospital, in fact you have mentored a20:21 into mp3 file 
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 number of our medical students and fellows and physician
assistants, and that is a big part of the program for you.Solomon
Training is key. Being able to help others implement techniques
which we know are effective is an important goal for us. 
Leslie and I often lecture to the physicians, nurses, and students
in all realms of the clinical arena to help them learn approaches
to pain and other symptom management.Foss
I know Larry, that you have gotten a number of our oncology fellows
interested in this whole area of palliative care and have
successfully sent a couple of those folks out into practice, which
is really remarkable.Solomon
We have had some wonderful young people to work with and that is an
exciting part of what we do.Foss
Leslie, from the point of view of nursing, is there now a nursing
specialty for APRNs for palliative care?Blatt
 There is a nursing specialty, but like with the physicians who can
come into palliative care with a wide variety of masters
programs.  It is also board certified, so most APRNs in
palliative care are board certified in that specialty as well, and
I would just like to say that we also have been involved in
teaching some of the masters students and actually our newest
addition to our service will be somebody that shared their clinical
experience with us.Foss
Leslie, could you talk a little bit from the point of view of the
family members, we have talked about some of the issues for the
patients, but it is hard for family members to accept the whole
concept of palliative care too. How do you work with them around
that issue?Blatt
 I think the concept of palliative care is really that we help
their family member have as good a quality of life as possible, and
once you get to know us, we joke around and say you cannot really
get rid of us, but people do seem to like us as a team as well.
Some other things that we can help families do is clarify the
medical information that they get. We have the luxury of having the
time and ability to be able to listen to a lot of their questions.
Now-a-days people get so much information that they think they
understand it, but it is really only after being able to talk about
it a couple of times that they are able to really comprehend it
cognitively in their minds, so we give them the time, we provide
support and reassurance and I think we also allow them to be able
to discuss some of their fears and worries that they have about
their family member and it is really helping them live oftentimes
in parallel realities.  We often say it is hoping for the
best, but also being prepared for the worst as well as emphasizing
what can be done. I think this is the most23:22 into mp3 file 
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 important point, that there is always something that can be done
for the patient and for the family whether it symptom control,
emotional support, preservation, or dignity.Foss
That's a key point for patients and for families, that even if the
situation looks bleak, there is always some element of hope that
you can help those folks in some way.Solomon
Importantly, hope can be focused on medications, cure, or treatment
of the disease, it can also be focused on completion of life goals
with family, friends, and spiritual completion as well.  Hope
is an ongoing element that we support.Foss
Another important point that I have certainly noticed in my
relationship with your practice is that there is oftentimes a
dichotomy between what you tell the patient and their family and
what they really understand, and you have often been able to get
involved in those discussion as well and help to focus back to the
reality and help everybody to get on the same page because you have
probably a better handle on what people are really thinking.Solomon
It's not so much a better handle as this is what we are focused on
doing. It is an old medical axiom that most of what you
solve in terms of patient's need starts and ends with the history
and having the time to listen to what the patient has to say, and
to asks questions back to be sure they understand our words and we
understand their words, and it helps to move the process
forward.Foss
So you have developed this outstanding palliative care program at
Yale-New Haven and I am wondering, are there programs like this at
other hospitals?Blatt
 There actually are and I think the growth of palliative care
programs has increased in the last eight years or so and the latest
figure right now is that 81% of hospitals with greater than 300
beds have palliative care programs.Foss
What are some of the future goals for palliative care, specifically
at Yale-New Haven?Solomon
At this point we have three major goals. First and foremost we are
in the process of increasing our staffing so that we can expand our
services both in the outpatient clinic arena and also broaden the
spectrum of illnesses that we see both inpatient and
outpatient.  Second, we believe that teaching is extremely
important and ultimately we hope to expand our role in that to
include a palliative fellowship program, and last, but not least,
all medicine has to move forward by careful investigation and we
believe research to improve what we do is essential and that this
must be done without compromising either the comfort or safety of
our patients and their families.26:09 into mp3 file 
http://yalecancercenter.org/podcast/aug0810-cancer-answers-solomon-blatt.mp3Blatt            
 Just one other goal that we have is to hopefully become involved
at the beginning of a life threatening illness or serious
illness.Foss
Now is there a way for that to happen from a practical point of
view?Solomon
Time, we hope as people become more exposed to what we do and more
comfortable that we are not an alternative, but a concurrent form
of treatment, I hope that will happen.  We work very hard to
communicate back to the physicians who refer to us so they
understand the process of what we are doing, that's one part,
second that we ensure continuity of care and consistency of care of
our patients and we hope that approach overtime will lead to
earlier involvement with patients with these illnesses.Foss
If a patient wants to find out more about palliative care, are
there websites, is there a palliative care foundation or other
resources available?Blatt
 There are lots of websites about palliative care and actually on
Smilow Cancer Center website there is a palliative care component
so people can look at Yale to get a better idea of us, and you can
Google palliative care and you will come up with a large number of
palliative care resources.Foss
Larry, could you talk a little bit about what clinical trials you
think might be interesting in the future to do in palliative
care?Solomon
We have a wish list of things that we would like to focus on,
simple things that need to be better understood.  We know some
medicines that have been effective in improving side effects
related to radiation therapy in one area of the body, and have not
been used in another, so we would like to look at that.  We
know that we make a lot of assumptions about how medicines are
absorbed, but those assumptions are based on people who are
otherwise well and we want to make sure that the same thing applies
to patient with the kinds of illnesses we deal with and we want to
look at the timeline of our involvement and patient care and the
use of sort of unusual agents in helping with neuropathies and
other side effects of treatments, so there are many things that we
have to think about and as time permits we will begin to look in
the coming year.Foss
And the use of pain control is something that obviously you are
involved in as well?Solomon
I think pain control is central to everything we do in that pain
impacts on so many other things, it affects mental status,
emotions, general well being, and the ability to function, so
looking for ways to make that better is always on our agenda.Foss
Thank you both for joining me tonight.  It has been really
great to get some detailed information29:08 into mp3 file 
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 and understanding about palliative care.  This is Dr.
Francine Foss from Yale Cancer Center wishing you a safe and
healthy week.If you have questions or would like to share your comments,
visit yalecancecenter.org where you can also subscribe to our pod
cast and find written transcription of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.