referrals to palliative care services medical oncology perspective kavi capildeo mbbs frcp(edin) dm...
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Cancer mortality in Trinidad and Tobago Jan Dec 2006: deaths –Male: 6876 Female: 5740 Top 5 causes of cancer death –Prostate20% –Breast11% –Colorectal10% –Bronchus and Lung8% –Leukemia6% Elizabeth Quamina Cancer Registry Elizabeth Quamina Cancer RegistryTRANSCRIPT
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Referrals to Palliative Care Services
Medical Oncology perspectiveKavi Capildeo MBBS FRCP(Edin) DM
SMO, Eastern Regional Health Authority
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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
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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
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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
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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?
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Oncology services in T&T
National Radiotherapy CentreRegional clinics: ERHA, SWRHA, Tobago2 private centresRadiation and medical oncologistsOncology nursesSocial workersPharmacists
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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
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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”
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No safety net?
Fall from clinic system→ a hard landing for the client?? Pressure to maintain status quo with continued efforts at chemo/RT
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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
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INCB and Trinidad
United Nations agencyRegulates international sale of narcotic drugsT&T- severe limitsChronic shortages
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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
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Why?
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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
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Oncology and Palliative Care
Both multidisciplinary, client centredOverlapping objectives– Quality of life and death– Symptom relief– Supportive care
Complementary roles
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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
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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
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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
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Palliative care- whose responsibility?
Palliative care is the responsibility of all health and social care professionals delivering care
(NICE, 2004)Specialist palliative care services
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“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
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21
Specialist Palliative Care Provision
Bradford & AiredaleManaged Clinical NetworkPalliative / End of Life CareEducation Programme
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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
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Holmes, S. Practicalities of palliative care. www.bradfordvts.co.uk Accessed Oct 16, 2011
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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
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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
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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
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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
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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
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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
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