Palliative Care

Transcript

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00:13 --> 00:19Welcome to Yale Cancer Answers with Dr. Anees Chagpar.
00:19 --> 00:29Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancer. This week
00:29 --> 00:36it's a conversation about the role of social work in palliative care for cancer patients with licensed clinical social worker Edward Schwartz.
00:36 --> 00:43Dr. Chagpar is a professor of surgery and oncology at Yale School of Medicine.
00:43 --> 00:43Maybe we can start
00:43 --> 00:49off by you telling us a little bit about yourself and what
00:49 --> 00:53exactly you do.
00:53 --> 00:57This is maybe a second or third career for me.
00:57 --> 01:01I was in the art community, and
01:01 --> 01:04worked for many years as a graphic designer.
01:04 --> 01:14I still paint and actually work through a lot of what I see and do in the palliative care community and end of life through my work.
01:14 --> 01:20And I was in Hospice prior to this.
01:20 --> 01:22I worked in inpatient Hospice.
01:22 --> 01:33I worked in the community and I worked in pediatric Hospice and then this great opportunity to come and work with this really unbelievably great team here at Smilow afforded
01:33 --> 01:36itself to me and I've just loved it.
01:36 --> 01:39I love what I do.
01:39 --> 01:41I'm often fascinated by
01:41 --> 01:51people's career trajectory. So you're going to have to go a little bit deeper for me and tell me how you go from being a graphic designer
01:51 --> 01:55to being involved in palliative care and
01:55 --> 02:04social work. Social work is something I'd wanted to do for a long,
02:04 --> 02:07long time. My wife is a social worker.
02:07 --> 02:13But at the time we were getting together and settling down,
02:13 --> 02:21she told me that this house isn't big enough for two social workers.
02:21 --> 02:24We weren't going to be making a lot of money,
02:24 --> 02:32so that was part of it and the fact that I think a lot of people who end up in palliative care have histories
02:32 --> 02:35with people who are facing
02:35 --> 02:44serious illness and or end of life and I have that history and so because of various
02:44 --> 02:51life events, you decided to leave graphic design as a profession and enter social work.
02:51 --> 03:00Yes I did and it's the best move I ever made and in particular into palliative care.
03:00 --> 03:03Tell us a little bit more
03:03 --> 03:08about palliative care. I think that many people understand what palliative care is,
03:08 --> 03:12but I think that there still may be some misperceptions.
03:12 --> 03:14I mean, certainly, you know,
03:14 --> 03:20we've had politicians who have had the view that palliative care is equivalent to death panels.
03:20 --> 03:24People may not know the difference between palliative care and Hospice.
03:24 --> 03:27You mentioned that you were involved in Hospice,
03:27 --> 03:32so can you clarify for us what exactly is palliative care?
03:32 --> 03:34What exactly is it that you do?
03:34 --> 03:46Palliative Care is really working with people with serious illness and who are experiencing, in my case,
03:46 --> 03:58working through the outpatient clinic, the palliative care clinic, we deal with people who are experiencing a great deal of cancer related pain,
03:58 --> 04:02so our objective is to comfort them,
04:02 --> 04:06alleviate that pain as much as possible.
04:06 --> 04:16and see them through the trajectory whether it's going up or down through this process of cancer.
04:16 --> 04:17Tell us
04:17 --> 04:22then the difference between palliative care and
04:22 --> 04:27pain management.
04:27 --> 04:34Good question. At this point, I would say that a good deal of what we do in palliative care is we treat people with
04:34 --> 04:40pain medication such as opioids and some really intensive pain medication,
04:40 --> 04:45whereas pain management less so they're more likely maybe to do more procedures.
04:45 --> 04:48I mean, I'm not a doctor,
04:48 --> 04:57but they're more likely to do procedures like pain blocks and that sort of thing at this point.
05:01 --> 05:04Ed, you're a social worker
05:04 --> 05:07you're not a doctor,
05:07 --> 05:10so how would
05:10 --> 05:12you prescribe opioids? Help
05:12 --> 05:15us to understand what exactly
05:15 --> 05:25you do.
05:25 --> 05:31I am there for emotional and psychosocial support. I try to be as close to where the patient is as possible.
05:31 --> 05:34I don't go in with an agenda,
05:34 --> 05:38I go in, find out where they are,
05:38 --> 05:40what their emotional state is
05:40 --> 05:46and try to again see where they are.
05:46 --> 05:53If they want to go to the place of talking about end of life,
05:53 --> 05:57I will go there. If they don't, then I won't.
05:57 --> 06:02I'm not going to push them this is their path.
06:02 --> 06:05And their their life. And
06:05 --> 06:09so palliative care, it seems to me,
06:09 --> 06:14is really where patients who have extreme difficulty with a particular illness,
06:14 --> 06:17in this case cancer,
06:17 --> 06:20are assessed by a multidisciplinary team,
06:20 --> 06:27part of which includes a physician who could manage their pain and their other symptoms
06:27 --> 06:35because I would anticipate that some of these patients might have terrible nausea or terrible difficulty in
06:35 --> 06:38eating or breathing,
06:38 --> 06:40but also have other issues,
06:40 --> 06:47because one can imagine that when you're facing such a tremendous illness as cancer,
06:47 --> 06:52that there are a number of things that go through your head,
06:52 --> 06:55your body, there's the physical issues,
06:55 --> 06:58but there's also the mental issues,
06:58 --> 07:00the emotional issues, the family issues,
07:00 --> 07:05the social issues, all of which is an extra burden on you, but they all are a piece
07:09 --> 07:13towards caring for these patients.
07:13 --> 07:24I like to think and someone actually once told me that coming into peoples lives at this time is almost like coming into a play
07:24 --> 07:31and you're sort of dropped from the top of the play into that particular scene or act that
07:31 --> 07:35the patient is in at that particular time.
07:35 --> 07:40If you didn't have anything to do with them prior to their illness,
07:40 --> 07:44and more than likely are going to have much to do with,
07:44 --> 07:49certainly not the patient going forward but the family for that matter,
07:49 --> 07:53though there are times when things carry through a little bit,
07:53 --> 07:55so you're there in that moment,
07:55 --> 07:57and that's what you're dealing with.
07:57 --> 08:03So whatever baggage they've come with and everybody has prior to
08:03 --> 08:11their illness, they have their history and that carries into the illness stage and carries into the stressors.
08:11 --> 08:16But again, you're not trying to fix what happened before,
08:16 --> 08:23you just trying to keep things as focused as possible on the patient,
08:23 --> 08:27the patient's care, and everybody's emotional well being as
08:27 --> 08:36much as possible. Tell us about some of the issues that patients discuss with you in those palliative care
08:36 --> 08:39talks.
08:39 --> 08:43It could be a myriad of things.
08:43 --> 08:52We will possibly talk about again some of their history,
08:52 --> 08:58how they are within their family unit.
08:58 --> 09:03Possibly what they experience,
09:03 --> 09:05estrangement from certain family members.
09:05 --> 09:13Are they looking to be at that point now that things are getting to a different stage in their life?
09:13 --> 09:16Are they looking for reconciliation of some kind?
09:16 --> 09:21Do they know where the family is that they're reaching out to?
09:21 --> 09:25Do they know where they are or how to contact them?
09:25 --> 09:35Or do they have an idea and we've even done things where we've called
09:35 --> 09:40through Google and other areas just to try and locate
09:40 --> 09:44family members and try to re invite people.
09:44 --> 09:56I think that is such a critical piece because sometimes cancer is that stressor that really kind of gives people a crystallized view of relationships.
09:56 --> 10:05Either relationships that they're in a bad relationship and it's falling apart and they just need that emotional support to say you're OK.
10:05 --> 10:09Maybe this was not a great relationship
10:09 --> 10:19and now it's just come to the forefront that this wasn't healthy for you and we're here to help you as you move on.
10:19 --> 10:23Or contrary to that point,
10:23 --> 10:29which was the desire to really work through relationships and strengthen those relationships.
10:29 --> 10:34Because you now have this event which is pulling people together.
10:34 --> 10:38Different patients come with different kinds of stressors.
10:38 --> 10:41Different family dynamics that really play in.
10:41 --> 10:52I guess the other thing Ed is that I can think of in terms of the family dynamic is with regards to children when
10:52 --> 11:02cancer effects the parent or grandparent and how they have that conversation with their child or their grandchild.
11:02 --> 11:12And the other side to that coin is what do you do when the patient is the child and children going through cancer?
11:12 --> 11:17I can imagine that puts tremendous stress on the family. Let's
11:17 --> 11:19talk a ittle bit about that.
11:19 --> 11:21In my
11:21 --> 11:28work as a
11:28 --> 11:39social worker, I don't really deal with children in the sense of children who are are dealing with cancer.
11:39 --> 11:43I did when I was in Hospice,
11:43 --> 11:46I dealt with Pediatrics quite a bit.
11:46 --> 11:50It depends. It depends on the age of the
11:50 --> 11:58child because at certain points if the child is very young,
11:58 --> 12:02obviously you're doing most of your work with the parents at that point.
12:02 --> 12:06If the child is more towards pre adolescence,
12:06 --> 12:10you're dealing with them and the parents and then up to 21
12:10 --> 12:16is really what's considered pediatric Hospice.
12:16 --> 12:28You're dealing a little bit more with that young adult patient and some with family of the parents, the dynamics obviously are different according to
12:28 --> 12:40the age, right? So a 21 year old who's dealing with end of life issues or cancer,
12:40 --> 12:48they've already had a history with their parents and there may be things that were going on
12:48 --> 12:54prior to their cancer diagnosis,
12:54 --> 13:02so that comes into play and how that intermingles and how they sort of
13:02 --> 13:11deal with how parents and children deal with the issues that they've dealt with before and how that sort of fits in with trying
13:11 --> 13:15to come to terms with their illness and what they want to
13:15 --> 13:17do with the rest of their lives.
13:17 --> 13:27Yeah, and I can imagine that it's a whole other dynamic when you have parents who are going through a cancer diagnosis and have young children and have to explain
13:27 --> 13:29to their child what's going on,
13:29 --> 13:34we're going to pick up on that conversation right after we take a short break for medical minute.
13:34 --> 13:42Please stay tuned to learn more about the role of social work in palliative care with my guest Ed Schwartz.
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14:04 --> 14:07as smoking involves the potent drug nicotine.
14:07 --> 14:10But it's a very important lifestyle change,
14:10 --> 14:13especially for patients undergoing cancer treatment.
14:13 --> 14:23Quitting smoking has been shown to positively impact response to treatments, decrease the likelihood that patients will develop second malignancies, and increase rates of survival.
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14:55 --> 14:55Welcome
14:55 --> 14:57back to Yale Cancer Answers.
14:57 --> 15:07This is doctor Anees Chagpar and I'm joined tonight by my guest Edward Schwartz and we're talking about his role in palliative care and right before the break
15:07 --> 15:15Ed we were talking about some of the things that you as a social worker do as part of that interdisciplinary team,
15:15 --> 15:25in palliative care and one of the things we mentioned was the idea of meeting patients where they were and kind of being dropped into their life
15:25 --> 15:29when they've just been faced with this massive diagnosis of cancer,
15:29 --> 15:33tell us a little bit about your role.
15:33 --> 15:39I can imagine that when an individual is faced with a diagnosis of cancer,
15:39 --> 15:44let alone all of the physical pain that they have to face,
15:44 --> 15:50the issues with regards to relationships in spouses and so on and so forth,
15:50 --> 15:53which we talked a little bit about,
15:53 --> 15:56but how do they convey that information?
15:56 --> 16:07To a young child. I can imagine that they're torn on the one hand you have to take care of yourself and you've got all of these medical
16:07 --> 16:15appointments and you're in pain and on the other hand you want to protect your child from this terrible diagnosis and the thought that
16:15 --> 16:18one day they might not have a parent.
16:18 --> 16:23But on the other hand you have to tell them and I'm sure that that can
16:23 --> 16:26be really frightening and harrowing for a lot of people.
16:26 --> 16:31It is and we we tend to give them either some literature to possibly read,
16:31 --> 16:34coach them through it a little bit.
16:34 --> 16:43And try to tell them to be as truthful as possible within the framework of the child's age,
16:43 --> 16:48right? So age appropriate explanation as to what's going on,
16:48 --> 16:50but again, to be honest,
16:50 --> 16:53to be somewhat realistic, not to
16:53 --> 17:03fantasize about what this is,
17:03 --> 17:05or where mom or dad are going,
17:05 --> 17:10that sort of thing. But just to be in the moment and be as realistic as possible.
17:10 --> 17:13I'm sure that must be difficult.
17:13 --> 17:20It's difficult and I'll ask the parents if they like for me to be sitting in on the meeting with them if that
17:20 --> 17:22would that make it easier?
17:22 --> 17:26And is it a situation where mom or dad has the illness?
17:28 --> 17:36At that point I don't know how realistic they've been with the children.
17:36 --> 17:37Some people are very realistic.
17:37 --> 17:40Some people have held it off till the end,
17:40 --> 17:43and so where do we go from there?
17:46 --> 17:50What I try to do is
17:50 --> 17:56if I can't speak to that patient who's ill and can't be in the room,
17:56 --> 18:07then I'm helping the surviving parent talk to their child as much as possible and not be afraid of that process.
18:07 --> 18:11And to be open about any questions they have.
18:11 --> 18:15Any questions those children might have because they do,
18:15 --> 18:19children have questions and children pick up on things
18:19 --> 18:21rather quickly, they hear things.
18:21 --> 18:28Obviously, we all know that they they hear things that we think they don't,
18:28 --> 18:31and if they have those
18:31 --> 18:35ideas in their head without explanation, it happens to adults too,
18:35 --> 18:38if you're given partial part of an explanation,
18:38 --> 18:40where does your mind go?
18:40 --> 18:44It doesn't go necessarily to the best places.
18:44 --> 18:46Most of the time, it doesn't.
18:46 --> 18:50It's going out to those really frightening areas,
18:50 --> 18:53and that's where honesty comes in,
18:53 --> 18:56but the compassion of the parent,
18:56 --> 19:01and if there's a professional involved to help them through that process,
19:01 --> 19:13I would imagine that another area of conversation that you as a social worker have with patients is with regards to their own sense of mortality
19:13 --> 19:20because I can imagine that when you're faced with a diagnosis of cancer,
19:20 --> 19:27that you become acutely aware of your own mortality and what that means and what happens.
19:27 --> 19:31And that's really scary. Talk a little bit
19:31 --> 19:39about that.
19:39 --> 19:44When I meet patients on the hospital side, I would do this and I do this on the palliative care side.
19:44 --> 19:47Also depending on where they are in
19:47 --> 19:52either disease progression or their treatment progression,
19:52 --> 19:55and depending on obviously as I said before,
19:55 --> 19:57I'm sort of taking their lead.
19:57 --> 20:06If I see that they are feeling very anxious about where they are in the process or if they're feeling somewhat depressed about it,
20:06 --> 20:08I will ask about
20:08 --> 20:13do they have fears or concerns about what is about to happen?
20:13 --> 20:17And have they thought about end of life?
20:17 --> 20:21I'm not necessarily that in their face about it,
20:21 --> 20:23but after conversing for awhile,
20:23 --> 20:25we sort of work through it.
20:25 --> 20:27And then if they are comfortable enough,
20:27 --> 20:29we start talking about it.
20:29 --> 20:34And many times they will talk about where they are and a lot of times they'll start by saying,
20:34 --> 20:37well, I'm not afraid of death.
20:37 --> 20:42What they are afraid of is the process getting there and many times that,
20:42 --> 20:46involves the pain that they're going to experience,
20:46 --> 20:48and then some other aspects.
20:48 --> 20:52What is it going to be like as I approach?
20:52 --> 20:57What can I expect? Am I going to be awake through this whole process,
20:57 --> 21:07or is there going to be a place where I'm not going to be awake and not going to be able to communicate?
21:07 --> 21:12It's a variety and depends on who the patient is,
21:12 --> 21:18if they know people that have had experience with situations in end of life.
21:18 --> 21:22Some people have had no experience with end of life at all.
21:22 --> 21:29So again, you're sort of playing with where they are at that particular moment in their lives.
21:29 --> 21:34A few times now you've mentioned Hospice and you've mentioned palliative care.
21:34 --> 21:37Can you put a finer point on the differences
21:37 --> 21:39between the two?
21:39 --> 21:43Yes, so
21:43 --> 21:56from a concrete place, hospice has to have a six month or or less diagnosis given by a physician.
21:56 --> 22:02Palliative care does not have that barrier.
22:02 --> 22:09The other thing is people who are undergoing palliative care are usually people who start off with a serious illness.
22:09 --> 22:19You do not have to be facing end of life and there's sort of the great myth that as soon as people here palliation or palliative that,
22:19 --> 22:27that means they're being referred for palliative care that somehow the doctor is telling him that this is it,
22:27 --> 22:30you're about to die. And that's far from the truth.
22:30 --> 22:33Yes, there is a place for
22:33 --> 22:41palliative care at end of life and taking people through to the Hospice place,
22:41 --> 22:44yes. Very much so. And
22:44 --> 22:50I would say we are comfortable with that and were trained well for that.
22:50 --> 22:53But again, palliative care does not have that.
22:53 --> 23:01That conversation that connotation of having to mean that you're facing the end of your life.
23:01 --> 23:07It is really to palliate symptoms as
23:07 --> 23:11you started with, let me say also around Hospice.
23:11 --> 23:14we use the word that people use
23:14 --> 23:16the word palliative care also,
23:16 --> 23:19and palliative means,
23:19 --> 23:24comfort calming, that's what the definition of the word is,
23:24 --> 23:27so it slips into Hospice,
23:27 --> 23:29but more as an
23:29 --> 23:36adjective as to what the treatment is going to be as opposed to
23:36 --> 23:39a practice which is what
23:39 --> 23:49palliative care is right. When you talk about some management in terms of palliative care and you started off by talking about,
23:49 --> 23:53you know controlling peoples pain often with opioids or strong painkillers,
23:53 --> 23:57which is the difference between palliative care and pain management?
23:57 --> 24:00For example, which can be more procedural.
24:00 --> 24:07I would imagine that yet another fear that people have when they hear opioids is
24:07 --> 24:09am I going to get addicted?
24:09 --> 24:18I mean we hear about the opioid crisis all the time and now here you are giving me opioids and you know what does this
24:18 --> 24:20mean? How do you deal with that?
24:20 --> 24:26I deal with it by saying doctors aren't here to create an addiction for you.
24:26 --> 24:31They're here to treat your pain and this is the best way they know
24:31 --> 24:38how to do it. You're under a doctors care, they're monitoring what's going on so it's,
24:38 --> 24:40from that standpoint,
24:40 --> 24:46you're in good hands. Is that to say that you can't develop some sort of
24:46 --> 24:51psychiatric dependence at some point?
24:51 --> 24:54Yeah, it's possible people are living longer with their illnesses,
24:54 --> 24:59and doing so are experiencing pain for longer periods of time.
24:59 --> 25:01And they do need that help.
25:01 --> 25:06But I would say not to be afraid of taking your pain medication.
25:06 --> 25:08It's there to help you,
25:08 --> 25:11and it's going to help your emotional state.
25:11 --> 25:16There's literature that shows that there's a real connection between people's emotional state
25:16 --> 25:20and their level of pain that they're experiencing,
25:20 --> 25:24so it's important to be as comfortable as possible if you can,
25:24 --> 25:30and two, we try to help people through that anxiety of becoming either addicts,
25:30 --> 25:32or drug dependent.
25:32 --> 25:35And so you've mentioned
25:35 --> 25:37how palliative care is really
25:37 --> 25:39a team approach,
25:39 --> 25:42you've got doctors who are prescribing opioids
25:42 --> 25:46to manage the medical symptoms,
25:46 --> 25:48whether it's pain or nausea,
25:48 --> 25:53constipation, or difficulty swallowing. I imagine that there are many,
25:53 --> 25:58many symptoms on the physical side that the medical professionals are dealing with,
25:58 --> 26:07and then you come in and you're really trying to deal with more emotional side and relationships with families with children.
26:07 --> 26:10And working through the fears that they may have at end of life,
26:10 --> 26:13I imagine that you would also help them when they're stressed about
26:13 --> 26:16what am I going to do in terms of my employment?
26:16 --> 26:19What am I going to do in terms of making ends meet?
26:19 --> 26:21How am I going to meet the financial bills,
26:21 --> 26:25right? Talk a little bit about that aspect of it as well.
26:25 --> 26:34All of those things play into what the patients and the families that we see and we all have
26:34 --> 26:37to play our part,
26:37 --> 26:43so we have a very holistic sense of how we treat people and there's overlap,
26:43 --> 26:47right? So doctors may be treating the pain through medication,
26:47 --> 26:54but they are also there to help them through the emotional aspects of what's going on in there.
26:54 --> 26:57Trained to listen and talk about those aspects.
26:57 --> 27:02APRNs, the same thing, nurses the same thing.
27:13 --> 27:17I like to tell people that probably 85 to 90%
27:17 --> 27:23of what I feel that I do is around their emotional and psychosocial needs.
27:23 --> 27:28But then there's the concrete areas and the concrete areas are very important
27:28 --> 27:30also because they can help
27:30 --> 27:43deviate anxiety, so helping someone get a grant for money to help them pay a bill for that month.
27:43 --> 27:48Those things, or transportation to and from the hospital.
27:48 --> 27:57All very important things. So it's anything that's really going to make the patient comfortable living.
27:57 --> 28:00Whether it's their pain or
28:00 --> 28:11their quality of life how they're dealing with their lives through this crisis.
28:11 --> 28:19I wonder, are there other members of the team who may deal with kind of the more spiritual aspects?
28:23 --> 28:26Yeah,
28:26 --> 28:30she's incredible.
28:30 --> 28:43She listens, and at times when people have more spiritual aspects of concern and those aren't things that I'm necessarily trained to do,
28:43 --> 28:50the chaplain comes in and is able to help quite a bit.
28:50 --> 28:53And not just through classic religious practice.
28:55 --> 29:04I think that's why we use the word spiritual now to take that connotation out that it's just around traditional religion.
29:04 --> 29:09You know, the chaplains are there to help you through any sort of existential
29:09 --> 29:14sort of crisis.
29:14 --> 29:23Edward Schwartz is a licensed clinical social worker. If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at Yalecancercenter.org.
29:23 --> 29:28We hope you'll join us next week to learn more about the fight against cancer here on Connecticut
29:28 --> 29:29public radio.

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Edward Schwartz

April 19, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

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