Referrals to Palliative Care Services

Medical Oncology perspectiveKavi 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 20%– Breast 11%– Colorectal 10%– Bronchus and Lung 8%– Leukemia 6%

Elizabeth Quamina Cancer Registry

Death

High

LowTime

Function

Death

High

LowTime

Function

Gradual decline e.g.Dementia, frailty

Death

High

LowTime

Function

Rapid decline eg. Cancer

Palliative care - trajectories

Erratic decline eg organ failure

Source: NHS Scotland

Oncology clients and palliative careWhat 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 CentreRegional clinics: ERHA, SWRHA, Tobago2 private centresRadiation and medical oncologistsOncology nursesSocial workersPharmacists

Palliative care within Oncology ClinicsEvaluation of pain and other symptomsPain medications, other drug therapiesPsychosocial support: Medical Social WorkerOncologic intervention with palliative intent– Radiation – Chemotherapy– Endocrine therapy– Targeted therapies– Palliative surgery

Palliative care in oncology clinic setting: limitations

Limited community outreachNo care facility for terminally ill in MoH serviceStaff have other duties– Radiation planning/delivery, chemo etc– No staff exclusively assigned to

palliative/supportive carePatient/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 agencyRegulates international sale of narcotic drugsT&T- severe limitsChronic shortages

Fentanyl

Hydro

morphone

Methad

one

Morphine

Oxycodone

Pethidine0

50000

100000

150000

200000

250000

300000

Canada g per million pop

Trinidad g per million

2011 drug alloca-tions in grams(expressed as quantity per mil-lion population)

http://www.incb.org/pdf/technical-reports/narcotic-drugs/2010/NAR_2010_EFS_Part3.pdf , ac-cessed Oct 15 2011Quantities per 1 million population calculated using 2009 World Bank population estimates

Why?

Palliative care in TTLimitations and challenges

Community-based, public-sector services– Absent in most areas– MoH support required

Hospice facilitiesOutpatient clinicsPersonnelTraining and educationEquipment and drugsPublic awareness

Oncology and Palliative Care

Both multidisciplinary, client centredOverlapping objectives– Quality of life and death– Symptom relief– Supportive care

Complementary roles

Kaplan–Meier Estimates of Survival According to Study Group.

Temel JS et al. N Engl J Med 2010;363:733-742.

Randomized trial of early palliative care referral vs standard care in pts with metastatic NSCLC•Higher QOL scores•Improved mood•Improved survival•Less aggressive end-of-life care

Appropriate referralsOncology staff, clients, families– Awareness of available services– Timely referral – Aware of referral pathways/protocols

Palliative care services– Refer when appropriate for intervention to

control symptomsPalliative RT: bone pain, SVCO, etcSystemic treatments

DEFINING PALLIATIVE CAREWorld 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 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)

When should a Service refer to Specialist Palliative Care?

Bradford & AiredaleManaged Clinical NetworkPalliative / End of Life CareEducation Programme

21

Specialist Palliative Care Provision

Bradford & AiredaleManaged Clinical NetworkPalliative / End of Life CareEducation Programme

Three triggers for Supportive/ Palliative Care

1. The surprise question: ‘Would you be surprised if this patient were to die

in the next 6-12 months?’ 2. Choice:

The patient with advanced disease makes a choice for comfort care

3. 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 deterioratingProgressive weight loss (>10%) over past 6 months2 or more unplanned admissions in last 6 monthsPatient is in a nursing /care home, or needs more care at homeHolmes, 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 comorbiditiesPersistent symptoms despite optimal palliative oncology treatmentToo frail for oncology treatment

Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011

Clinical indicators for terminal careQ1. Could this patient be in the last daysof life?

Confined to bed/chair or unable to self careDifficulty taking oral fluids or not tolerating artificial feeding/hydrationNo longer able to take oral medicationIncreasingly 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, end-of-

life care– Appropriate and timely referral to specialist

palliative care services (where available)– Gaps in system need to be addressed