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Data-driven changes, pathways, and physician buy-in
Improvements in the quality of health care don’t just happen. They’re created, in physician practices large and small, and driven by the desire to improve. Three oncologists, one in a solo practice, a second practicing in a midsize group, and a third in a large medical system, spoke at the 2012 ASCO Quality Care Symposium in San Diego about their quality-improvement initiatives — what they’re doing, how they’re doing it, and the obstacles they face in their efforts to improve the quality of cancer care.
*Click on the links to the left for a PDF of the full article and accompanying Commentary.
Improvements in the quality of health care don’t just happen. They’re created, in physician practices large and small, and driven by the desire to improve. Three oncologists, one in a solo practice, a second practicing in a midsize group, and a third in a large medical system, spoke at the 2012 ASCO Quality Care Symposium in San Diego about their quality-improvement initiatives — what they’re doing, how they’re doing it, and the obstacles they face in their efforts to improve the quality of cancer care.
*Click on the links to the left for a PDF of the full article and accompanying Commentary.
Improvements in the quality of health care don’t just happen. They’re created, in physician practices large and small, and driven by the desire to improve. Three oncologists, one in a solo practice, a second practicing in a midsize group, and a third in a large medical system, spoke at the 2012 ASCO Quality Care Symposium in San Diego about their quality-improvement initiatives — what they’re doing, how they’re doing it, and the obstacles they face in their efforts to improve the quality of cancer care.
*Click on the links to the left for a PDF of the full article and accompanying Commentary.
Clinical pathways: are we there yet?
For nearly a decade, The US Oncology Network has been on a journey toward the widespread use of evidence-based clinical pathways in oncology. The road has been sometimes rocky, and the path occasionally branching and uncertain. But we have recognized that enhancing value is good for all stakeholders and we are confident that with new collaborations and expanded access through technology we will be able to deliver high-quality cancer care to patients. When we introduced pathways, some payers voiced concern that our use of pathways would actually cost them more, not less. Furthermore, some oncologists were concerned that they would be forfeiting patient outcomes and their clinical freedom to choose their own treatments for their patients based on their medical judgment. The US Oncology Network has published reassuring data to address both of those concerns...
*Click on the links to the left for a PDF of the full article and accompanying Commentary.
For nearly a decade, The US Oncology Network has been on a journey toward the widespread use of evidence-based clinical pathways in oncology. The road has been sometimes rocky, and the path occasionally branching and uncertain. But we have recognized that enhancing value is good for all stakeholders and we are confident that with new collaborations and expanded access through technology we will be able to deliver high-quality cancer care to patients. When we introduced pathways, some payers voiced concern that our use of pathways would actually cost them more, not less. Furthermore, some oncologists were concerned that they would be forfeiting patient outcomes and their clinical freedom to choose their own treatments for their patients based on their medical judgment. The US Oncology Network has published reassuring data to address both of those concerns...
*Click on the links to the left for a PDF of the full article and accompanying Commentary.
For nearly a decade, The US Oncology Network has been on a journey toward the widespread use of evidence-based clinical pathways in oncology. The road has been sometimes rocky, and the path occasionally branching and uncertain. But we have recognized that enhancing value is good for all stakeholders and we are confident that with new collaborations and expanded access through technology we will be able to deliver high-quality cancer care to patients. When we introduced pathways, some payers voiced concern that our use of pathways would actually cost them more, not less. Furthermore, some oncologists were concerned that they would be forfeiting patient outcomes and their clinical freedom to choose their own treatments for their patients based on their medical judgment. The US Oncology Network has published reassuring data to address both of those concerns...
*Click on the links to the left for a PDF of the full article and accompanying Commentary.
A randomized, double-blind, placebo-controlled study of oral coenzyme Q 10 to relieve self-reported treatment-related fatigue in newly diagnosed patients with breast cancer
Glenn J. Lesser, MD, Doug Case, PhD, Nancy Stark, RN, PhD, et al
Background Coenzyme Q10 (CoQ10) is a common antioxidant supplement with known cardioprotective effects and potential anticancer benefits.
Objectives We performed a randomized, double-blind, placebo-controlled study of oral CoQ10 in female breast cancer patients with the primary objective of determining CoQ10 ’s effects on self-reported fatigue, depression, and quality of life (QOL).
Methods Eligible women with newly diagnosed breast cancer and planned adjuvant chemotherapy were randomized to oralsupplements of 300 mg CoQ10 or placebo, each combined with 300 IU vitamin E, divided into 3 daily doses. Treatment wascontinued for 24 weeks. Blood tests, QOL measures, and levels of plasma CoQ10 and vitamin E were obtained at baseline and at 8,16, and 24 weeks. Mixed-effects models were used to assess treatment differences in outcomes over time.
Results Between September 2004 and March 2009, 236 women were enrolled. Treatment arms were well balanced with respect to age(range, 28-85 years), pathologic stage (stage 0, 91%; stage I, 8%; stage II, 1%), ethnicity (white, 87%; black, 11%; Hispanic, 2%), and planned therapy. Baseline CoQ10 levels in the CoQ10 and placebo arms were 0.70 and 0.73 g/mL, respectively; the 24-week CoQ10 levels were 1.83 and 0.79g/mL, respectively. There were no significant differences between the CoQ10 and placebo arms at 24 weeks for scores on the Profile of Mood States–Fatigue questionnaire (least squares means, 7.08 vs 8.24, P = .257), the Functional Assessment of Chronic Illness Therapy–Fatigue tool (37.6 vs 37.6, P = .965), the Functional Assessment of Cancer Therapy–Breast Cancer instrument (111.9 vs 110.4, P = .577), or the Center for Epidemiologic Studies–Depression scale (11.6 vs 12.3, P = .632).
Conclusions Supplementation with conventional doses of CoQ10 led to sustained increases in plasma CoQ10 levels but did not result in improved self-reported fatigue or QOL after 24 weeks of treatment.
*For a PDF of the full article, click on the link to the left of this introduction.
Glenn J. Lesser, MD, Doug Case, PhD, Nancy Stark, RN, PhD, et al
Background Coenzyme Q10 (CoQ10) is a common antioxidant supplement with known cardioprotective effects and potential anticancer benefits.
Objectives We performed a randomized, double-blind, placebo-controlled study of oral CoQ10 in female breast cancer patients with the primary objective of determining CoQ10 ’s effects on self-reported fatigue, depression, and quality of life (QOL).
Methods Eligible women with newly diagnosed breast cancer and planned adjuvant chemotherapy were randomized to oralsupplements of 300 mg CoQ10 or placebo, each combined with 300 IU vitamin E, divided into 3 daily doses. Treatment wascontinued for 24 weeks. Blood tests, QOL measures, and levels of plasma CoQ10 and vitamin E were obtained at baseline and at 8,16, and 24 weeks. Mixed-effects models were used to assess treatment differences in outcomes over time.
Results Between September 2004 and March 2009, 236 women were enrolled. Treatment arms were well balanced with respect to age(range, 28-85 years), pathologic stage (stage 0, 91%; stage I, 8%; stage II, 1%), ethnicity (white, 87%; black, 11%; Hispanic, 2%), and planned therapy. Baseline CoQ10 levels in the CoQ10 and placebo arms were 0.70 and 0.73 g/mL, respectively; the 24-week CoQ10 levels were 1.83 and 0.79g/mL, respectively. There were no significant differences between the CoQ10 and placebo arms at 24 weeks for scores on the Profile of Mood States–Fatigue questionnaire (least squares means, 7.08 vs 8.24, P = .257), the Functional Assessment of Chronic Illness Therapy–Fatigue tool (37.6 vs 37.6, P = .965), the Functional Assessment of Cancer Therapy–Breast Cancer instrument (111.9 vs 110.4, P = .577), or the Center for Epidemiologic Studies–Depression scale (11.6 vs 12.3, P = .632).
Conclusions Supplementation with conventional doses of CoQ10 led to sustained increases in plasma CoQ10 levels but did not result in improved self-reported fatigue or QOL after 24 weeks of treatment.
*For a PDF of the full article, click on the link to the left of this introduction.
Glenn J. Lesser, MD, Doug Case, PhD, Nancy Stark, RN, PhD, et al
Background Coenzyme Q10 (CoQ10) is a common antioxidant supplement with known cardioprotective effects and potential anticancer benefits.
Objectives We performed a randomized, double-blind, placebo-controlled study of oral CoQ10 in female breast cancer patients with the primary objective of determining CoQ10 ’s effects on self-reported fatigue, depression, and quality of life (QOL).
Methods Eligible women with newly diagnosed breast cancer and planned adjuvant chemotherapy were randomized to oralsupplements of 300 mg CoQ10 or placebo, each combined with 300 IU vitamin E, divided into 3 daily doses. Treatment wascontinued for 24 weeks. Blood tests, QOL measures, and levels of plasma CoQ10 and vitamin E were obtained at baseline and at 8,16, and 24 weeks. Mixed-effects models were used to assess treatment differences in outcomes over time.
Results Between September 2004 and March 2009, 236 women were enrolled. Treatment arms were well balanced with respect to age(range, 28-85 years), pathologic stage (stage 0, 91%; stage I, 8%; stage II, 1%), ethnicity (white, 87%; black, 11%; Hispanic, 2%), and planned therapy. Baseline CoQ10 levels in the CoQ10 and placebo arms were 0.70 and 0.73 g/mL, respectively; the 24-week CoQ10 levels were 1.83 and 0.79g/mL, respectively. There were no significant differences between the CoQ10 and placebo arms at 24 weeks for scores on the Profile of Mood States–Fatigue questionnaire (least squares means, 7.08 vs 8.24, P = .257), the Functional Assessment of Chronic Illness Therapy–Fatigue tool (37.6 vs 37.6, P = .965), the Functional Assessment of Cancer Therapy–Breast Cancer instrument (111.9 vs 110.4, P = .577), or the Center for Epidemiologic Studies–Depression scale (11.6 vs 12.3, P = .632).
Conclusions Supplementation with conventional doses of CoQ10 led to sustained increases in plasma CoQ10 levels but did not result in improved self-reported fatigue or QOL after 24 weeks of treatment.
*For a PDF of the full article, click on the link to the left of this introduction.
Relationship between arm morbidity and patient-reported outcomes following surgery in women with node-negative breast cancer: NSABP protocol B-32
Background The impact of arm morbidity following breast cancer surgery on patient-observed changes in daily functioningand health-related quality of life (HRQoL) has not been well-studied.
Objective To examine the association of objective measures such as range of motion (ROM) and lymphedema, with patient-reported outcomes (PROs) in the arm and breast, upper extremity function, activities, and HRQoL.
Methods The National Surgical Adjuvant Breast and Bowel Project Protocol B-32 was a randomized trial comparingsentinel node resection (SNR) with axillary dissection (AD) in women with node-negative breast cancer. ROM and armvolume were measured objectively. PROs included symptoms; arm function; limitations in social, recreational, occupational,and other regular activities; and a global index of HRQoL. Statistical methods included cross-tabulations and multivariablelinear regression models.
Results In all, 744 women provided at least 1 postsurgery assessment. About one-third of the patients experienced arm mobility restrictions. A similar number of patients avoided the use of the arm 6 months after surgery. Limitations in work and other regular activities were reported by about a quarter of the patients. In this multivariable analysis, arm mobility and sensory neuropathy were predictors of patient-reported arm function and overall HRQoL. Predictors for activity limitations also included side of surgery (dominant vs nondominant). Edema was not significant after adjustment for sensory neuropathy and ROM.
Limitations Arm mobility and edema were measured simultaneously only once during the follow-up (6 months).
Conclusion Clinical measures of sensory neuropathy and restrictions in arm mobility following breast cancer surgery are associated with self-reported limitations in activity and reductions in overall HRQoL.
Click on the PDF icon at the top of this introduction to read the full article.
Background The impact of arm morbidity following breast cancer surgery on patient-observed changes in daily functioningand health-related quality of life (HRQoL) has not been well-studied.
Objective To examine the association of objective measures such as range of motion (ROM) and lymphedema, with patient-reported outcomes (PROs) in the arm and breast, upper extremity function, activities, and HRQoL.
Methods The National Surgical Adjuvant Breast and Bowel Project Protocol B-32 was a randomized trial comparingsentinel node resection (SNR) with axillary dissection (AD) in women with node-negative breast cancer. ROM and armvolume were measured objectively. PROs included symptoms; arm function; limitations in social, recreational, occupational,and other regular activities; and a global index of HRQoL. Statistical methods included cross-tabulations and multivariablelinear regression models.
Results In all, 744 women provided at least 1 postsurgery assessment. About one-third of the patients experienced arm mobility restrictions. A similar number of patients avoided the use of the arm 6 months after surgery. Limitations in work and other regular activities were reported by about a quarter of the patients. In this multivariable analysis, arm mobility and sensory neuropathy were predictors of patient-reported arm function and overall HRQoL. Predictors for activity limitations also included side of surgery (dominant vs nondominant). Edema was not significant after adjustment for sensory neuropathy and ROM.
Limitations Arm mobility and edema were measured simultaneously only once during the follow-up (6 months).
Conclusion Clinical measures of sensory neuropathy and restrictions in arm mobility following breast cancer surgery are associated with self-reported limitations in activity and reductions in overall HRQoL.
Click on the PDF icon at the top of this introduction to read the full article.
Background The impact of arm morbidity following breast cancer surgery on patient-observed changes in daily functioningand health-related quality of life (HRQoL) has not been well-studied.
Objective To examine the association of objective measures such as range of motion (ROM) and lymphedema, with patient-reported outcomes (PROs) in the arm and breast, upper extremity function, activities, and HRQoL.
Methods The National Surgical Adjuvant Breast and Bowel Project Protocol B-32 was a randomized trial comparingsentinel node resection (SNR) with axillary dissection (AD) in women with node-negative breast cancer. ROM and armvolume were measured objectively. PROs included symptoms; arm function; limitations in social, recreational, occupational,and other regular activities; and a global index of HRQoL. Statistical methods included cross-tabulations and multivariablelinear regression models.
Results In all, 744 women provided at least 1 postsurgery assessment. About one-third of the patients experienced arm mobility restrictions. A similar number of patients avoided the use of the arm 6 months after surgery. Limitations in work and other regular activities were reported by about a quarter of the patients. In this multivariable analysis, arm mobility and sensory neuropathy were predictors of patient-reported arm function and overall HRQoL. Predictors for activity limitations also included side of surgery (dominant vs nondominant). Edema was not significant after adjustment for sensory neuropathy and ROM.
Limitations Arm mobility and edema were measured simultaneously only once during the follow-up (6 months).
Conclusion Clinical measures of sensory neuropathy and restrictions in arm mobility following breast cancer surgery are associated with self-reported limitations in activity and reductions in overall HRQoL.
Click on the PDF icon at the top of this introduction to read the full article.
Prospective validation of a prediction tool for identifying patients at high risk for chemotherapy-induced nausea and vomiting
George Dranitsaris, BPharm, PhD, Nathaniel Bouganim, MD, Carolyn Milano, Lisa Vandermeer, MSc, Susan Dent, MD, Paul Wheatley-Price, MD, Jenny Laporte, RN, Karen-Ann Oxborough, RN, and Mark Clemons, MD
Background Even with modern antiemetic regimens, up to 20% of cancer patients suffer from moderate to severechemotherapy-induced nausea and vomiting (CINV) (grade 2). We previously developed chemotherapy cycle–based risk predictive models forgrade 2 acute and delayed CINV. In this study, the prospective validation of the prediction models andassociated scoring systems is described.
Objective Our objective was to prospectively validate prediction models designed to identify patients at high risk for moderate tosevere CINV.
Methods Patients receiving chemotherapy were provided with CINV symptom diaries. Prior to each cycle of chemotherapy, the acute and delayed CINV scoring systems were used to stratify patients into low- and high-risk groups. Logistic regression was used tocompare the occurrence of grade 2 CINV between patients considered by the model to be at high vs low risk. The external validity of each system was assessed via an area under the receiver operating characteristic (AUROC) curve analysis.
Results Outcome data were collected from 97 patients following 401 cycles of chemotherapy. The incidence of grade 2 acute and delayed CINV was 13.5% and 21.4%, respectively. There was a significant correlation between the risk score and the probability of developing acute and delayed CINV following chemotherapy. Both the acute and delayed scoring systems had good predictive accuracy when applied to the validation sample (acute, AUROC = 0.70, 95% CI, 0.62– 0.77; delayed, AUROC = 0.75, 95% CI, 0.69 – 0.80). Patients who were identified as high risk were 3.1 (P = .006) and 4.2 (P < .001) times more likely to develop grade 2 acute and delayed CINV than were those identified as low risk.
Conclusion This study demonstrates that the scoring systems are able to accurately identify patients at high risk for acute and delayed CINV.
*For a PDF of the full article, click on the link to the left of this introduction.
George Dranitsaris, BPharm, PhD, Nathaniel Bouganim, MD, Carolyn Milano, Lisa Vandermeer, MSc, Susan Dent, MD, Paul Wheatley-Price, MD, Jenny Laporte, RN, Karen-Ann Oxborough, RN, and Mark Clemons, MD
Background Even with modern antiemetic regimens, up to 20% of cancer patients suffer from moderate to severechemotherapy-induced nausea and vomiting (CINV) (grade 2). We previously developed chemotherapy cycle–based risk predictive models forgrade 2 acute and delayed CINV. In this study, the prospective validation of the prediction models andassociated scoring systems is described.
Objective Our objective was to prospectively validate prediction models designed to identify patients at high risk for moderate tosevere CINV.
Methods Patients receiving chemotherapy were provided with CINV symptom diaries. Prior to each cycle of chemotherapy, the acute and delayed CINV scoring systems were used to stratify patients into low- and high-risk groups. Logistic regression was used tocompare the occurrence of grade 2 CINV between patients considered by the model to be at high vs low risk. The external validity of each system was assessed via an area under the receiver operating characteristic (AUROC) curve analysis.
Results Outcome data were collected from 97 patients following 401 cycles of chemotherapy. The incidence of grade 2 acute and delayed CINV was 13.5% and 21.4%, respectively. There was a significant correlation between the risk score and the probability of developing acute and delayed CINV following chemotherapy. Both the acute and delayed scoring systems had good predictive accuracy when applied to the validation sample (acute, AUROC = 0.70, 95% CI, 0.62– 0.77; delayed, AUROC = 0.75, 95% CI, 0.69 – 0.80). Patients who were identified as high risk were 3.1 (P = .006) and 4.2 (P < .001) times more likely to develop grade 2 acute and delayed CINV than were those identified as low risk.
Conclusion This study demonstrates that the scoring systems are able to accurately identify patients at high risk for acute and delayed CINV.
*For a PDF of the full article, click on the link to the left of this introduction.
George Dranitsaris, BPharm, PhD, Nathaniel Bouganim, MD, Carolyn Milano, Lisa Vandermeer, MSc, Susan Dent, MD, Paul Wheatley-Price, MD, Jenny Laporte, RN, Karen-Ann Oxborough, RN, and Mark Clemons, MD
Background Even with modern antiemetic regimens, up to 20% of cancer patients suffer from moderate to severechemotherapy-induced nausea and vomiting (CINV) (grade 2). We previously developed chemotherapy cycle–based risk predictive models forgrade 2 acute and delayed CINV. In this study, the prospective validation of the prediction models andassociated scoring systems is described.
Objective Our objective was to prospectively validate prediction models designed to identify patients at high risk for moderate tosevere CINV.
Methods Patients receiving chemotherapy were provided with CINV symptom diaries. Prior to each cycle of chemotherapy, the acute and delayed CINV scoring systems were used to stratify patients into low- and high-risk groups. Logistic regression was used tocompare the occurrence of grade 2 CINV between patients considered by the model to be at high vs low risk. The external validity of each system was assessed via an area under the receiver operating characteristic (AUROC) curve analysis.
Results Outcome data were collected from 97 patients following 401 cycles of chemotherapy. The incidence of grade 2 acute and delayed CINV was 13.5% and 21.4%, respectively. There was a significant correlation between the risk score and the probability of developing acute and delayed CINV following chemotherapy. Both the acute and delayed scoring systems had good predictive accuracy when applied to the validation sample (acute, AUROC = 0.70, 95% CI, 0.62– 0.77; delayed, AUROC = 0.75, 95% CI, 0.69 – 0.80). Patients who were identified as high risk were 3.1 (P = .006) and 4.2 (P < .001) times more likely to develop grade 2 acute and delayed CINV than were those identified as low risk.
Conclusion This study demonstrates that the scoring systems are able to accurately identify patients at high risk for acute and delayed CINV.
*For a PDF of the full article, click on the link to the left of this introduction.
Nausea and vomiting in advanced cancer: the Cleveland Clinic protocol
Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution’s practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic.
Click on the PDF icon at the top of this introduction to read the full article.
Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution’s practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic.
Click on the PDF icon at the top of this introduction to read the full article.
Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution’s practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic.
Click on the PDF icon at the top of this introduction to read the full article.
Initiating palliative care conversations: lessons from Jewish bioethics
What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding thepreservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff’sethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty toinform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.
Click on the PDF icon at the top of this introduction to read the full article.
What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding thepreservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff’sethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty toinform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.
Click on the PDF icon at the top of this introduction to read the full article.
What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding thepreservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff’sethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty toinform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.
Click on the PDF icon at the top of this introduction to read the full article.
A Randomized, Controlled Trial of Panax quinquefolius Extract (CVT-E002) to Reduce Respiratory Infection in Patients With Chronic Lymphocytic Leukemia
Kevin P. High, MD, MS; Doug Case, PhD; MD, David Hurd, MD; Bayard Powell, MD; Glenn Lesser, MD; Ann R. Falsey, MD; Robert Siegel, MD; Joanna Metzner-Sadurski, MD; John C. Krauss, MD; Bernard Chinnasami, MD, George Sanders, MD, Steven Rousey, MD, Edward G. Shaw, MD
Abstract
Background
Chronic lymphocytic leukemia (CLL) patients are at high risk for acute respiratory illness (ARI).
Objective
We evaluated the safety and efficacy of a proprietary extract of Panax quinquefolius, CVT-E002, in reducing ARI.
Methods
This was a double-blind, placebo-controlled, randomized trial of 293 subjects with early-stage, untreated CLL conducted January–March 2009.
Results
ARI was common, occurring on about 10% of days during the study period. There were no significant differences of the 2 a priori primary end points: ARI days (8.5 ± 17.2 for CVT-E002 vs 6.8 ± 13.3 for placebo) and severe ARI days (2.9 ± 9.5 for CVT-E002 vs 2.6 ± 9.8 for placebo). However, 51% of CVT-E002 vs 56% of placebo recipients experienced at least 1 ARI (difference, −5%; 95% confidence interval [CI], −16% to 7%); more intense ARI occurred in 32% of CVT-E002 vs 39% of placebo recipients (difference, −7%; 95% CI, −18% to 4%), and symptom-specific evaluation showed reduced moderate to severe sore throat (P = .004) and a lower rate of grade ≥3 toxicities (P = .02) in CVT-E002 recipients. Greater seroconversion (4-fold increases in antibody titer) vs 9 common viral pathogens was documented in CVT-E002 recipients (16% vs 7%, P = .04).
Limitations
Serologic evaluation of antibody titers was not tied to a specific illness, but covered the entire study period.
Conclusion
CVT-E002 was well tolerated. It did not reduce the number of ARI days or antibiotic use; however, there was a trend toward reduced rates of moderate to severe ARI and significantly less sore throat, suggesting that the increased rate of seroconversion most likely reflects CVT-E002-enhanced antibody responses.
*For a PDF of the full article and accompanying commentary by Paul Sloan, click on the links to the left of this introduction.
Kevin P. High, MD, MS; Doug Case, PhD; MD, David Hurd, MD; Bayard Powell, MD; Glenn Lesser, MD; Ann R. Falsey, MD; Robert Siegel, MD; Joanna Metzner-Sadurski, MD; John C. Krauss, MD; Bernard Chinnasami, MD, George Sanders, MD, Steven Rousey, MD, Edward G. Shaw, MD
Abstract
Background
Chronic lymphocytic leukemia (CLL) patients are at high risk for acute respiratory illness (ARI).
Objective
We evaluated the safety and efficacy of a proprietary extract of Panax quinquefolius, CVT-E002, in reducing ARI.
Methods
This was a double-blind, placebo-controlled, randomized trial of 293 subjects with early-stage, untreated CLL conducted January–March 2009.
Results
ARI was common, occurring on about 10% of days during the study period. There were no significant differences of the 2 a priori primary end points: ARI days (8.5 ± 17.2 for CVT-E002 vs 6.8 ± 13.3 for placebo) and severe ARI days (2.9 ± 9.5 for CVT-E002 vs 2.6 ± 9.8 for placebo). However, 51% of CVT-E002 vs 56% of placebo recipients experienced at least 1 ARI (difference, −5%; 95% confidence interval [CI], −16% to 7%); more intense ARI occurred in 32% of CVT-E002 vs 39% of placebo recipients (difference, −7%; 95% CI, −18% to 4%), and symptom-specific evaluation showed reduced moderate to severe sore throat (P = .004) and a lower rate of grade ≥3 toxicities (P = .02) in CVT-E002 recipients. Greater seroconversion (4-fold increases in antibody titer) vs 9 common viral pathogens was documented in CVT-E002 recipients (16% vs 7%, P = .04).
Limitations
Serologic evaluation of antibody titers was not tied to a specific illness, but covered the entire study period.
Conclusion
CVT-E002 was well tolerated. It did not reduce the number of ARI days or antibiotic use; however, there was a trend toward reduced rates of moderate to severe ARI and significantly less sore throat, suggesting that the increased rate of seroconversion most likely reflects CVT-E002-enhanced antibody responses.
*For a PDF of the full article and accompanying commentary by Paul Sloan, click on the links to the left of this introduction.
Kevin P. High, MD, MS; Doug Case, PhD; MD, David Hurd, MD; Bayard Powell, MD; Glenn Lesser, MD; Ann R. Falsey, MD; Robert Siegel, MD; Joanna Metzner-Sadurski, MD; John C. Krauss, MD; Bernard Chinnasami, MD, George Sanders, MD, Steven Rousey, MD, Edward G. Shaw, MD
Abstract
Background
Chronic lymphocytic leukemia (CLL) patients are at high risk for acute respiratory illness (ARI).
Objective
We evaluated the safety and efficacy of a proprietary extract of Panax quinquefolius, CVT-E002, in reducing ARI.
Methods
This was a double-blind, placebo-controlled, randomized trial of 293 subjects with early-stage, untreated CLL conducted January–March 2009.
Results
ARI was common, occurring on about 10% of days during the study period. There were no significant differences of the 2 a priori primary end points: ARI days (8.5 ± 17.2 for CVT-E002 vs 6.8 ± 13.3 for placebo) and severe ARI days (2.9 ± 9.5 for CVT-E002 vs 2.6 ± 9.8 for placebo). However, 51% of CVT-E002 vs 56% of placebo recipients experienced at least 1 ARI (difference, −5%; 95% confidence interval [CI], −16% to 7%); more intense ARI occurred in 32% of CVT-E002 vs 39% of placebo recipients (difference, −7%; 95% CI, −18% to 4%), and symptom-specific evaluation showed reduced moderate to severe sore throat (P = .004) and a lower rate of grade ≥3 toxicities (P = .02) in CVT-E002 recipients. Greater seroconversion (4-fold increases in antibody titer) vs 9 common viral pathogens was documented in CVT-E002 recipients (16% vs 7%, P = .04).
Limitations
Serologic evaluation of antibody titers was not tied to a specific illness, but covered the entire study period.
Conclusion
CVT-E002 was well tolerated. It did not reduce the number of ARI days or antibiotic use; however, there was a trend toward reduced rates of moderate to severe ARI and significantly less sore throat, suggesting that the increased rate of seroconversion most likely reflects CVT-E002-enhanced antibody responses.
*For a PDF of the full article and accompanying commentary by Paul Sloan, click on the links to the left of this introduction.
Online network offers 24/7 patient support
When a cancer patient from Menomonie, Wis., reached out to the American Cancer Society’s WhatNext online network seeking treatment reassurance, a ready-made support group jumped into action.
"Anyone familiar with 5-FU [5-fluorouracil], cetuximab (Erbitux), or carboplatin? Has anyone ever worn a pump?" asked Packerbacker. "New nodule revealed metastatic cancer. ... I had cisplatin in the past and tolerated it with minor side effects. I’m still nervous, though. Wish me luck?"
An optimistic response came from a user in New Jersey: "I received 5-FU via a pump. ... Not fun, more of a pain in the butt. It turned out to not be a big deal at all," wrote IKickedIt.
"Good luck!" wrote FreeBird in Tampa, Fla. "Dad had carboplatin and Taxol [paclitaxel] for his previous lung cancer. He did really well with it!"
Patients and family members of patients described how to wear the pump, how to shower with the pump (by using plastic wrap and a shower head from a home improvement store), and how to disguise the pump (in a "cute backpack," suggested one user). Another user wrote, "Just kept the pump on my desk."
The new network boasts more than 10,000 registered users who pose questions and offer suggestions on topics both weighty and mundane.
"For those of you who had both options available, how did you decide between a lumpectomy and a mastectomy?" asked a mom from Cincinnati.
"Best advice for a caregiver who gets a bad cold?" queried Iibcarolek from California. "First of all, take care of yourself," advised Fizztig, who recommended frequent hand washing, using hand sanitizer, protecting sneezes, and getting enough rest.
By negotiating the well-organized website, users will find categories where they can share their experience and journey. Categories include "Oh, No," "Celebration," "Decision Point," and "Procedure or Surgery."
The website is organized by diagnosis. There is also a Pinboard where users can search, browse, or post inspirational photos and videos (similar to Pinterest).
One photo on the Pinboard is of a young girl wearing a scarf on her head with the following note from bcncnabb: "People stare. You all know this. You’ve all felt it in restaurants, at the grocery store, or any other place where people don’t get it. ... But wow, what people don’t notice is the fight, the spirit, and the grace that it takes to live with cancer."
Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society (ACS), endorsed the new online tool as an "exciting" use of technology to extend the reach of both the ACS and the oncology community. "We know that people who connect with each other in times like this feel more empowered, less anxious, and can approach this crucial time in their lives feeling supported," he noted.
The website’s exchange of practical tips reminded me of a caregiver’s lament about the difficulties of managing her husband’s percutaneous endoscopic gastrostomy (PEG) tube, which even the visiting in-home nurses didn’t really understand. In the exhausting days following his discharge after surgery for esophageal cancer, she taught herself how to triple flush the tube to prevent middle-of-the-night clogs.
Today, I would refer her to WhatNext, where I’m confident she would receive (and offer) pep talks and helpful advice.
In some cases, connections formed on WhatNext have led to offline friendships. The ACS highlighted a bond formed between MGM48 and MichaelV, both of whom have prostate cancer. "We compare notes and discuss life with cancer," said MGM48. "I’m happy to have a live sounding board sometimes.
"Let’s face it, no one outside really completely gets it," he said.
Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.
When a cancer patient from Menomonie, Wis., reached out to the American Cancer Society’s WhatNext online network seeking treatment reassurance, a ready-made support group jumped into action.
"Anyone familiar with 5-FU [5-fluorouracil], cetuximab (Erbitux), or carboplatin? Has anyone ever worn a pump?" asked Packerbacker. "New nodule revealed metastatic cancer. ... I had cisplatin in the past and tolerated it with minor side effects. I’m still nervous, though. Wish me luck?"
An optimistic response came from a user in New Jersey: "I received 5-FU via a pump. ... Not fun, more of a pain in the butt. It turned out to not be a big deal at all," wrote IKickedIt.
"Good luck!" wrote FreeBird in Tampa, Fla. "Dad had carboplatin and Taxol [paclitaxel] for his previous lung cancer. He did really well with it!"
Patients and family members of patients described how to wear the pump, how to shower with the pump (by using plastic wrap and a shower head from a home improvement store), and how to disguise the pump (in a "cute backpack," suggested one user). Another user wrote, "Just kept the pump on my desk."
The new network boasts more than 10,000 registered users who pose questions and offer suggestions on topics both weighty and mundane.
"For those of you who had both options available, how did you decide between a lumpectomy and a mastectomy?" asked a mom from Cincinnati.
"Best advice for a caregiver who gets a bad cold?" queried Iibcarolek from California. "First of all, take care of yourself," advised Fizztig, who recommended frequent hand washing, using hand sanitizer, protecting sneezes, and getting enough rest.
By negotiating the well-organized website, users will find categories where they can share their experience and journey. Categories include "Oh, No," "Celebration," "Decision Point," and "Procedure or Surgery."
The website is organized by diagnosis. There is also a Pinboard where users can search, browse, or post inspirational photos and videos (similar to Pinterest).
One photo on the Pinboard is of a young girl wearing a scarf on her head with the following note from bcncnabb: "People stare. You all know this. You’ve all felt it in restaurants, at the grocery store, or any other place where people don’t get it. ... But wow, what people don’t notice is the fight, the spirit, and the grace that it takes to live with cancer."
Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society (ACS), endorsed the new online tool as an "exciting" use of technology to extend the reach of both the ACS and the oncology community. "We know that people who connect with each other in times like this feel more empowered, less anxious, and can approach this crucial time in their lives feeling supported," he noted.
The website’s exchange of practical tips reminded me of a caregiver’s lament about the difficulties of managing her husband’s percutaneous endoscopic gastrostomy (PEG) tube, which even the visiting in-home nurses didn’t really understand. In the exhausting days following his discharge after surgery for esophageal cancer, she taught herself how to triple flush the tube to prevent middle-of-the-night clogs.
Today, I would refer her to WhatNext, where I’m confident she would receive (and offer) pep talks and helpful advice.
In some cases, connections formed on WhatNext have led to offline friendships. The ACS highlighted a bond formed between MGM48 and MichaelV, both of whom have prostate cancer. "We compare notes and discuss life with cancer," said MGM48. "I’m happy to have a live sounding board sometimes.
"Let’s face it, no one outside really completely gets it," he said.
Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.
When a cancer patient from Menomonie, Wis., reached out to the American Cancer Society’s WhatNext online network seeking treatment reassurance, a ready-made support group jumped into action.
"Anyone familiar with 5-FU [5-fluorouracil], cetuximab (Erbitux), or carboplatin? Has anyone ever worn a pump?" asked Packerbacker. "New nodule revealed metastatic cancer. ... I had cisplatin in the past and tolerated it with minor side effects. I’m still nervous, though. Wish me luck?"
An optimistic response came from a user in New Jersey: "I received 5-FU via a pump. ... Not fun, more of a pain in the butt. It turned out to not be a big deal at all," wrote IKickedIt.
"Good luck!" wrote FreeBird in Tampa, Fla. "Dad had carboplatin and Taxol [paclitaxel] for his previous lung cancer. He did really well with it!"
Patients and family members of patients described how to wear the pump, how to shower with the pump (by using plastic wrap and a shower head from a home improvement store), and how to disguise the pump (in a "cute backpack," suggested one user). Another user wrote, "Just kept the pump on my desk."
The new network boasts more than 10,000 registered users who pose questions and offer suggestions on topics both weighty and mundane.
"For those of you who had both options available, how did you decide between a lumpectomy and a mastectomy?" asked a mom from Cincinnati.
"Best advice for a caregiver who gets a bad cold?" queried Iibcarolek from California. "First of all, take care of yourself," advised Fizztig, who recommended frequent hand washing, using hand sanitizer, protecting sneezes, and getting enough rest.
By negotiating the well-organized website, users will find categories where they can share their experience and journey. Categories include "Oh, No," "Celebration," "Decision Point," and "Procedure or Surgery."
The website is organized by diagnosis. There is also a Pinboard where users can search, browse, or post inspirational photos and videos (similar to Pinterest).
One photo on the Pinboard is of a young girl wearing a scarf on her head with the following note from bcncnabb: "People stare. You all know this. You’ve all felt it in restaurants, at the grocery store, or any other place where people don’t get it. ... But wow, what people don’t notice is the fight, the spirit, and the grace that it takes to live with cancer."
Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society (ACS), endorsed the new online tool as an "exciting" use of technology to extend the reach of both the ACS and the oncology community. "We know that people who connect with each other in times like this feel more empowered, less anxious, and can approach this crucial time in their lives feeling supported," he noted.
The website’s exchange of practical tips reminded me of a caregiver’s lament about the difficulties of managing her husband’s percutaneous endoscopic gastrostomy (PEG) tube, which even the visiting in-home nurses didn’t really understand. In the exhausting days following his discharge after surgery for esophageal cancer, she taught herself how to triple flush the tube to prevent middle-of-the-night clogs.
Today, I would refer her to WhatNext, where I’m confident she would receive (and offer) pep talks and helpful advice.
In some cases, connections formed on WhatNext have led to offline friendships. The ACS highlighted a bond formed between MGM48 and MichaelV, both of whom have prostate cancer. "We compare notes and discuss life with cancer," said MGM48. "I’m happy to have a live sounding board sometimes.
"Let’s face it, no one outside really completely gets it," he said.
Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist.
'I never know when to call palliative care'
This morbidity and mortality conference was like any other: First, we reviewed the case of a patient with a complication from anticoagulation and then another with an anastomotic leak. Finally, we discussed an elderly patient who had a major emergent procedure to treat complications from an underlying life-limiting condition, only to die in hospital weeks later after developing insurmountable medical, surgical, and infectious complications.
This elderly patient was a man in his mid-70s recently diagnosed with recurrent melanoma. He came to our emergency department with peritonitis and hypotension. His wife of 52 years sat beside him. She was tearful and afraid. "We want everything done," she said. Eight weeks ago, he was working full time and playing golf. But, 6 weeks ago he became confused. A CT scan revealed brain metastasis. He spent 5 of the last 6 weeks in the ICU and in a step-down unit, or a nursing home after a series of complications from his brain biopsy. Now he was back in the hospital with a bowel perforation.
Before our surgical team even saw him, he was told he needed surgery, or he would die. We discussed the surgical risks including the likelihood of a protracted ICU stay, and the high risk he would never go home. Still, he and his wife were unprepared for death and so we went to the operating room.
The following weeks were fraught with complications. His symptoms – including delirium, tumor headaches, and pain – were all difficult to manage on his cocktail of steroids, opiates, and antipsychotics. Occasionally, he would mumble something about dying but we couldn’t determine if he was lucid. His symptoms and "talk about death" were distressing for his family. All in all, our team spent almost an hour each day answering their questions and tending to their anxiety and suffering. It took a high emotional toll on our entire team, as we each worried to ourselves that we were doing more harm than good.
One organ system failed after the other. And finally, after two operations, 10 different consultants, and 3 weeks in the hospital, we stopped talking about organ systems and told the family that this man was dying. That day we consulted palliative care to help us with "goals of care." The next day, he became oliguric, and we shifted our focus to comfort. He died within hours surrounded by his loving extended family.
When we discussed this case at M&M, there were no objections to the decision to operate or how we managed his laundry list of complications. His death was deemed "nonpreventable." But, at then end of the discussion, a colleague asked, with some exasperation, "I never know when to call palliative care. How do you decide when the patient is dying?"
In retrospect, it is clear that this patient was dying when we met him in the emergency department. He was malnourished and disabled from his cancer and treatment. His bowel perforation was caused by the steroids prescribed to treat his underlying terminal disease. The best outcome we could hope for was a good quality of life in his last days, a peaceful and dignified death, and an uncomplicated bereavement for his survivors. Our emergency, life-saving surgery was, in fact, palliative. Death was near, but we just didn’t want him to die this way.
According to the American College of Surgeons code of professional conduct, surgeons play a pivotal role in facilitating the transition from curative to palliative treatment for the patients and the entire health care team. Furthermore, "effective palliation obligates sensitive discussion with patients and their families." These conversations can be particularly onerous for surgeons because we take on tremendous sense of personal responsibility for postoperative outcomes. Once we commit to operating on a patient, their death, especially if it follows complications, can be equated with personal defeat. We may benefit from consulting specialists who can help us set the stage, and smooth the transition for our patients and their families. Surgeons may also personally benefit from the support of other providers to help us cope with these emotionally difficult cases.
Palliative care is a multidisciplinary model of care to address the physical, intellectual, emotional, social, and spiritual needs of patients and families facing serious illness. The goal of palliative care is to support the best possible quality of life for patients at all stages of serious illness, through providing aggressive symptom management, psychosocial and spiritual care, and grief and bereavement counseling before and after death. Palliative care seeks to be life affirming and is based on the understanding of death as a normal life process. It can and should be delivered along with life-prolonging treatment.
In this case, palliative care should have been offered in the emergency department as soon as this patient was admitted to our service. The patient, and his family, would have benefited from a team of physicians, nurses, pharmacists, social workers, and chaplains with the time and expertise to manage distressing symptoms from his cancer, and attend to the grief and suffering that characterized his final weeks. Earlier palliative care may have also steered us away from the slog of high-burden treatments that ultimately offered him little benefit. For the surgeons, palliative care would have provided additional resources to take the best possible care of our patient who, whether or not he made it home, was near the end of his life from an advanced illness.
Dr. Zara Cooper is an ACS Fellow, and assistant professor of surgery, Harvard Medical School, and department of surgery, division of trauma, burns and critical care at Brigham and Women’s Hospital, Boston. Dr. Cooper has no disclosures relevant to this editorial.
This morbidity and mortality conference was like any other: First, we reviewed the case of a patient with a complication from anticoagulation and then another with an anastomotic leak. Finally, we discussed an elderly patient who had a major emergent procedure to treat complications from an underlying life-limiting condition, only to die in hospital weeks later after developing insurmountable medical, surgical, and infectious complications.
This elderly patient was a man in his mid-70s recently diagnosed with recurrent melanoma. He came to our emergency department with peritonitis and hypotension. His wife of 52 years sat beside him. She was tearful and afraid. "We want everything done," she said. Eight weeks ago, he was working full time and playing golf. But, 6 weeks ago he became confused. A CT scan revealed brain metastasis. He spent 5 of the last 6 weeks in the ICU and in a step-down unit, or a nursing home after a series of complications from his brain biopsy. Now he was back in the hospital with a bowel perforation.
Before our surgical team even saw him, he was told he needed surgery, or he would die. We discussed the surgical risks including the likelihood of a protracted ICU stay, and the high risk he would never go home. Still, he and his wife were unprepared for death and so we went to the operating room.
The following weeks were fraught with complications. His symptoms – including delirium, tumor headaches, and pain – were all difficult to manage on his cocktail of steroids, opiates, and antipsychotics. Occasionally, he would mumble something about dying but we couldn’t determine if he was lucid. His symptoms and "talk about death" were distressing for his family. All in all, our team spent almost an hour each day answering their questions and tending to their anxiety and suffering. It took a high emotional toll on our entire team, as we each worried to ourselves that we were doing more harm than good.
One organ system failed after the other. And finally, after two operations, 10 different consultants, and 3 weeks in the hospital, we stopped talking about organ systems and told the family that this man was dying. That day we consulted palliative care to help us with "goals of care." The next day, he became oliguric, and we shifted our focus to comfort. He died within hours surrounded by his loving extended family.
When we discussed this case at M&M, there were no objections to the decision to operate or how we managed his laundry list of complications. His death was deemed "nonpreventable." But, at then end of the discussion, a colleague asked, with some exasperation, "I never know when to call palliative care. How do you decide when the patient is dying?"
In retrospect, it is clear that this patient was dying when we met him in the emergency department. He was malnourished and disabled from his cancer and treatment. His bowel perforation was caused by the steroids prescribed to treat his underlying terminal disease. The best outcome we could hope for was a good quality of life in his last days, a peaceful and dignified death, and an uncomplicated bereavement for his survivors. Our emergency, life-saving surgery was, in fact, palliative. Death was near, but we just didn’t want him to die this way.
According to the American College of Surgeons code of professional conduct, surgeons play a pivotal role in facilitating the transition from curative to palliative treatment for the patients and the entire health care team. Furthermore, "effective palliation obligates sensitive discussion with patients and their families." These conversations can be particularly onerous for surgeons because we take on tremendous sense of personal responsibility for postoperative outcomes. Once we commit to operating on a patient, their death, especially if it follows complications, can be equated with personal defeat. We may benefit from consulting specialists who can help us set the stage, and smooth the transition for our patients and their families. Surgeons may also personally benefit from the support of other providers to help us cope with these emotionally difficult cases.
Palliative care is a multidisciplinary model of care to address the physical, intellectual, emotional, social, and spiritual needs of patients and families facing serious illness. The goal of palliative care is to support the best possible quality of life for patients at all stages of serious illness, through providing aggressive symptom management, psychosocial and spiritual care, and grief and bereavement counseling before and after death. Palliative care seeks to be life affirming and is based on the understanding of death as a normal life process. It can and should be delivered along with life-prolonging treatment.
In this case, palliative care should have been offered in the emergency department as soon as this patient was admitted to our service. The patient, and his family, would have benefited from a team of physicians, nurses, pharmacists, social workers, and chaplains with the time and expertise to manage distressing symptoms from his cancer, and attend to the grief and suffering that characterized his final weeks. Earlier palliative care may have also steered us away from the slog of high-burden treatments that ultimately offered him little benefit. For the surgeons, palliative care would have provided additional resources to take the best possible care of our patient who, whether or not he made it home, was near the end of his life from an advanced illness.
Dr. Zara Cooper is an ACS Fellow, and assistant professor of surgery, Harvard Medical School, and department of surgery, division of trauma, burns and critical care at Brigham and Women’s Hospital, Boston. Dr. Cooper has no disclosures relevant to this editorial.
This morbidity and mortality conference was like any other: First, we reviewed the case of a patient with a complication from anticoagulation and then another with an anastomotic leak. Finally, we discussed an elderly patient who had a major emergent procedure to treat complications from an underlying life-limiting condition, only to die in hospital weeks later after developing insurmountable medical, surgical, and infectious complications.
This elderly patient was a man in his mid-70s recently diagnosed with recurrent melanoma. He came to our emergency department with peritonitis and hypotension. His wife of 52 years sat beside him. She was tearful and afraid. "We want everything done," she said. Eight weeks ago, he was working full time and playing golf. But, 6 weeks ago he became confused. A CT scan revealed brain metastasis. He spent 5 of the last 6 weeks in the ICU and in a step-down unit, or a nursing home after a series of complications from his brain biopsy. Now he was back in the hospital with a bowel perforation.
Before our surgical team even saw him, he was told he needed surgery, or he would die. We discussed the surgical risks including the likelihood of a protracted ICU stay, and the high risk he would never go home. Still, he and his wife were unprepared for death and so we went to the operating room.
The following weeks were fraught with complications. His symptoms – including delirium, tumor headaches, and pain – were all difficult to manage on his cocktail of steroids, opiates, and antipsychotics. Occasionally, he would mumble something about dying but we couldn’t determine if he was lucid. His symptoms and "talk about death" were distressing for his family. All in all, our team spent almost an hour each day answering their questions and tending to their anxiety and suffering. It took a high emotional toll on our entire team, as we each worried to ourselves that we were doing more harm than good.
One organ system failed after the other. And finally, after two operations, 10 different consultants, and 3 weeks in the hospital, we stopped talking about organ systems and told the family that this man was dying. That day we consulted palliative care to help us with "goals of care." The next day, he became oliguric, and we shifted our focus to comfort. He died within hours surrounded by his loving extended family.
When we discussed this case at M&M, there were no objections to the decision to operate or how we managed his laundry list of complications. His death was deemed "nonpreventable." But, at then end of the discussion, a colleague asked, with some exasperation, "I never know when to call palliative care. How do you decide when the patient is dying?"
In retrospect, it is clear that this patient was dying when we met him in the emergency department. He was malnourished and disabled from his cancer and treatment. His bowel perforation was caused by the steroids prescribed to treat his underlying terminal disease. The best outcome we could hope for was a good quality of life in his last days, a peaceful and dignified death, and an uncomplicated bereavement for his survivors. Our emergency, life-saving surgery was, in fact, palliative. Death was near, but we just didn’t want him to die this way.
According to the American College of Surgeons code of professional conduct, surgeons play a pivotal role in facilitating the transition from curative to palliative treatment for the patients and the entire health care team. Furthermore, "effective palliation obligates sensitive discussion with patients and their families." These conversations can be particularly onerous for surgeons because we take on tremendous sense of personal responsibility for postoperative outcomes. Once we commit to operating on a patient, their death, especially if it follows complications, can be equated with personal defeat. We may benefit from consulting specialists who can help us set the stage, and smooth the transition for our patients and their families. Surgeons may also personally benefit from the support of other providers to help us cope with these emotionally difficult cases.
Palliative care is a multidisciplinary model of care to address the physical, intellectual, emotional, social, and spiritual needs of patients and families facing serious illness. The goal of palliative care is to support the best possible quality of life for patients at all stages of serious illness, through providing aggressive symptom management, psychosocial and spiritual care, and grief and bereavement counseling before and after death. Palliative care seeks to be life affirming and is based on the understanding of death as a normal life process. It can and should be delivered along with life-prolonging treatment.
In this case, palliative care should have been offered in the emergency department as soon as this patient was admitted to our service. The patient, and his family, would have benefited from a team of physicians, nurses, pharmacists, social workers, and chaplains with the time and expertise to manage distressing symptoms from his cancer, and attend to the grief and suffering that characterized his final weeks. Earlier palliative care may have also steered us away from the slog of high-burden treatments that ultimately offered him little benefit. For the surgeons, palliative care would have provided additional resources to take the best possible care of our patient who, whether or not he made it home, was near the end of his life from an advanced illness.
Dr. Zara Cooper is an ACS Fellow, and assistant professor of surgery, Harvard Medical School, and department of surgery, division of trauma, burns and critical care at Brigham and Women’s Hospital, Boston. Dr. Cooper has no disclosures relevant to this editorial.
