Embedded integration of palliative care in an academic outpatient cancer center.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 158-158
Author(s):  
Christian T Sinclair
Keyword(s):  
Palliative Care ◽  
Medical Center ◽  
Descriptive Analysis ◽  
Gynecologic Oncology ◽  
Academic Medical Center ◽  
Cancer Center ◽  
Care Utilization ◽  
Cancer Type ◽  
Multiple Cancer ◽  
Care Clinic

158 Background: Palliative care is no longer reserved for ICUs and inpatient settings, since it can be delivered at any age and any stage regardless of goals of care. Oncologists are beginning to embrace more upstream palliative care but translating that to the long term setting has unique difficulties. Outpatient palliative care is a vital component to quality oncology care, but few examples of successful integration have been demonstrated. Methods: Data was collected from the palliative care clinic at the University of Kansas Medical Center Westwood Cancer Center. Descriptive analysis of the initial and current programs as well as successful outreach and education projects will be discussed. Quantitative analysis of number of initial and follow-up outpatient visits, cancer type, referring service and referring physician are all included. Hospice utilization was also recorded as well as length of time from initial consult to either death, discharge or calendar date June 30, 2015. Results: Since the pilot clinical program of outpatient palliative care in 2012 with two half day clinic sessions focused on BMT patients, the program has expanded to 5 half-day sessions and includes medical oncology, surgical oncology and gynecologic oncology. Referrals to palliative care have grown consistently covering multiple cancer diagnosis and including the entire oncology staff instead of a few champions. Increase in outpatient utilization has also spurred more early and appropriate inpatient palliative care utilization. Staff have moved from crisis-only use of outpatient palliative care to a co-management model. Conclusions: Outpatient palliative care can be successfully integrated into an NCI academic medical center oncology practice. (Note: More detailed data will be presented at the conference on all of the trends mentioned above.)

Usefulness of the Surprise Question on an Inpatient Oncology Service

2018 ◽  
Vol 35 (11) ◽  
pp. 1421-1425 ◽  
Author(s):  
Sarguni Singh ◽  
Adrian Rodriguez ◽  
Darrell Lee ◽  
Sung-Joon Min ◽  
Stacy Fischer
Keyword(s):  
Palliative Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Medicine ◽  
Medical Setting ◽  
Improvement Project ◽  
Care Clinic ◽  
Oncology Service ◽  
Multidisciplinary Rounds ◽  
Surprise Question

Background: Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon. Objective: We introduced the surprise question (SQ), “Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?,” at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt. Design, Setting, Patients: This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ. Measurements: Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention. Results: Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses’ estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.

Integrating contemplative and spiritual care in outpatient palliative care: A pilot study.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 247-247
Author(s):  
Craig D Blinderman ◽  
Alex Beth Schapiro
Keyword(s):  
Palliative Care ◽  
Spiritual Care ◽  
Descriptive Analysis ◽  
Care Program ◽  
Well Being ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Pilot Program ◽  
Palliative Care Program ◽  
Care Clinic

247 Background: Spiritual support is associated with better outcomes in cancer care and at the end of life (1, 2). Consensus guidelines advocate for incorporating spiritual care in the provision of specialist level palliative care (3). Contemplative care practices and chaplaincy interventions have the potential for mitigating existential distress, cultivating prognostic awareness, and fostering spiritual approaches to grieving and coping with advanced cancer. We present the results of a pilot program demonstrating the feasibility and impact of integrating a contemplative care chaplain in an outpatient palliative care program in a culturally diverse patient population in a large, academic cancer center. Methods: Case series and descriptive analysis. A description of 10 cases seen by a contemplative care chaplain in our outpatient palliative care clinic in the Herbert Irving Comprehensive Cancer Center (HICCC) at Columbia University will be presented. A descriptive analysis using a chaplaincy-centered model of assessment will highlight the domains of suffering and subjective integration of psychosocial and spiritual concepts. Results: Patients were generally in favor of meeting with and sharing their feelings openly with the chaplain. Patients’ describe important domains pertinent to their well being: meaning, family integration, spiritual practices, existential concerns, prognostic awareness. Subjective transformation and integration of the following constructs: “healing,” “gratitude,” “anger,” “hope,” “fear” were possible with only a few patient encounters. None of the patients were opposed to an initial visit and assessment. In only one case, the family requested not having further visits due to strong emotional reactions that came up. Conclusions: Preliminary results from a novel, pilot program integrating contemplative and spiritual care in an outpatient palliative care program suggest that it is a feasible intervention and should be considered in other cancer centers. Further studies will need to qualify and quantify the additional value and impact of spiritual care integrated in ambulatory palliative care services.

External validation of the simple prognostic score in a palliative care clinic at a comprehensive cancer center.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. e19566-e19566
Author(s):  
Brinder Vij ◽  
Stacy Marie Stabler ◽  
Howard T. Thaler ◽  
Paul A. Glare
Keyword(s):  
Palliative Care ◽  
Karnofsky Performance Status ◽  
Prognostic Score ◽  
External Validation ◽  
Comprehensive Cancer Center ◽  
Rank Test ◽  
Cancer Center ◽  
Cancer Type ◽  
Care Clinic ◽  
Percentage Difference

e19566 Background: Accurate survival predictions are essential for the optimal delivery of palliative care (PC). Clinical predictions of survival are notoriously inaccurate. Tools for making objective survival estimates in ambulatory cancer patients, who have months or years to live, are lacking. The Simple Prognostic Score (SPS) separated Canadian palliative radiotherapy patients into three groups with 12, 6 and 3 months median survivals, respectively. The aim of this study was to test the SPS in an outpatient PC clinic at a U.S. comprehensive cancer center. Methods: Retrospective chart review of 300 consecutive patients referred to one PC clinic at Memorial Sloan-Kettering Cancer Center (MSKCC). Cancer type, metastatic sites and Karnofsky performance status (KPS) score were used to calculate SPS (1 point each for non-breast cancer; non-osseous metastases; KPS score <70%). Outcome was date of death, obtained from the MSKCC institutional data base. Survival analysis was performed. Discrimination (non-overlap between groups) and calibration (percentage difference between estimated and observed survival) were measures of accuracy. Results: 79% (236 of 300) patients had advanced disease. Of them, 90% had cancers other than breast; 76% had metastases in sites other than bone; 27% had a low KPS score. The SPS score was 2 or 3 in 80%. By 10/31/11, 85% had died (median survival 4.9 months). SPS categorized the sample into four prognostic subgroups (see Table), with median survivals of 15, 9, 5 and 2 months respectively (log rank test χ2=38.71, d.f .3, p<0.0001). SPS was not very accurate, with poor discrimination (extensive intergroup overlap) but reasonable calibration (6-15% for the different groups). Conclusions: The SPS is user-friendly and helpful at the group level, but inaccurate at the individual level. Additional variables may narrow the prediction intervals, but will make the tool more complex. [Table: see text]

“Ask me, do you want to know the big picture?” Gynecologic oncology patient and provider perspectives on discussing prognosis.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 37-37
Author(s):  
Carolyn Lefkowits ◽  
Dio Kavalieratos ◽  
Janet Arida ◽  
Winifred Teuteberg ◽  
Heidi Donovan ◽  
...  
Keyword(s):  
Palliative Care ◽  
Life Expectancy ◽  
Medical Center ◽  
Gynecologic Oncology ◽  
Academic Medical Center ◽  
Gynecologic Cancer ◽  
Advanced Practice ◽  
Care Providers ◽  
Provider Perspectives ◽  
Patient And Provider Perspectives

37 Background: Prognosis affects decision making by providers and patients and accurate understanding of prognosis may help avoid futile end-of-life care. Gynecologic oncology (GO) patient and provider perspectives on discussing prognosis have not been described. We sought to analyze patient and provider preferences regarding timing, amount and type of information included in discussions of prognosis. Methods: Semi-structured qualitative interviews regarding palliative care with 19 GO providers (7 physicians, 7 advanced practice providers, 5 nurses) and 29 patients with advanced or recurrent gynecologic cancer at an academic medical center. Communication about prognosis was one interview domain. Two coders independently and iteratively analyzed transcripts using qualitative analysis. Results: Median patient age was 61, the most common cancer was ovary (59%) and 90% had recurrent disease. Providers were 74% female with median 15 years in practice. Themes included patients wanting frank discussions about prognosis, not limited to life expectancy. Further preferences regarding timing and content were individualized. All categories of providers reported having prognosis conversations. Providers saw these conversations as part of their clinical role, though they often found them difficult. Providers commonly equated prognosis purely with life expectancy. Providers recognized variation among patients in preferences regarding these conversations, but did not discuss asking patients directly about their preferences. Conclusions: GO patients want frank discussions about what the future might hold, often including but not limited to life expectancy. Providers see these discussions as being within their scope of practice but often find them difficult. Opportunities exist for provider education regarding communication skills for assessing patient preferences and conducting patient centered prognosis discussions. Education should include GO physicians, advanced practice providers and nurses. Collaboration with specialty palliative care providers could facilitate that education and provide assistance with challenging cases.

A trainee-led quality improvement project to improve rates of palliative care utilization in patients with advanced cancer.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 51-51
Author(s):  
Ramy Sedhom ◽  
Arjun Gupta ◽  
Mirat Shah ◽  
Kristen Marrone ◽  
Ilene S. Browner ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advanced Cancer ◽  
Metastatic Cancer ◽  
Cancer Center ◽  
Care Utilization ◽  
First Year ◽  
Post Intervention ◽  
Improvement Project ◽  
Care Clinic ◽  
Ancillary Staff

51 Background: ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. 1st year oncology fellows at our institution identified low rates of palliative care in their longitudinal clinic as an avenue for improvement. Methods: A Fellow-led multidisciplinary team aimed to increase palliative care utilization for patients with advanced cancer followed in first-year fellows’ clinic from baseline 11.5% (5/43 patients, Jul-Dec, '18) to 30% over a 4-mo period. Utilization was defined as evaluation in the outpatient palliative care clinic hosted in the cancer center. The team identified several barriers to referral: orders difficult to find in EMR, multiple consulting mechanisms (EMR, by phone, in person), EMR request not activating formal consult, no centralized scheduler to contact/confirm appointment, and poor awareness of team structure. PDSA cycles were implemented based on identified opportunities. Data were obtained from the EMR. Results: The PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and dissemination of process changes. The PDSA was implemented Jan-Apr '19. Rates of palliative care use increased from 11.5% pre-intervention to 43% (27/62 patients) post-intervention. In addition, median time to evaluation in palliative care clinic after placing a consult improved from 23 days (range, 10-60 days) to 12 days (range, 6-19 days). Conclusions: A multidisciplinary approach and classic QI methodology improved palliative care use for patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional support of efforts. Straightforward EMR interventions and ancillary staff use are effective in addressing under referrals.

Early Palliative Care for Patients With Brain Metastases Decreases Inpatient Admissions and Need for Imaging Studies

2018 ◽  
Vol 35 (8) ◽  
pp. 1069-1075 ◽  
Author(s):  
Akram Habibi ◽  
S. Peter Wu ◽  
Daniel Gorovets ◽  
Alexandra Sansosti ◽  
Marc Kryger ◽  
...  
Keyword(s):  
Health Care ◽  
Palliative Care ◽  
Brain Metastases ◽  
Health Care Utilization ◽  
Karnofsky Performance Status ◽  
Medical Center ◽  
Performance Status ◽  
Academic Medical Center ◽  
Emergency Department Visits ◽  
Care Utilization

Background: Early encounters with palliative care (PC) can influence health-care utilization, clinical outcome, and cost. Aim: To study the effect of timing of PC encounters on brain metastasis patients at an academic medical center. Setting/Participants: All patients diagnosed with brain metastases from January 2013 to August 2015 at a single institution with inpatient and/or outpatient PC records available for review (N = 145). Design: Early PC was defined as having a PC encounter within 8 weeks of diagnosis with brain metastases; late PC was defined as having PC after 8 weeks of diagnosis. Propensity score matched cohorts of early (n = 46) and late (n = 46) PC patients were compared to control for differences in age, gender, and Karnofsky Performance Status (KPS) at diagnosis. Details of the palliative encounter, patient outcomes, and health-care utilization were collected. Results: Early PC versus late PC patients had no differences in baseline KPS, age, or gender. Early PC patients had significantly fewer number of inpatient visits per patient (1.5 vs 2.9; P = .004), emergency department visits (1.2 vs 2.1; P = .006), positron emission tomography/computed tomography studies (1.2 vs 2.7, P = .005), magnetic resonance imaging scans (5.8 vs 8.1; P = .03), and radiosurgery procedures (0.6 vs 1.3; P < .001). There were no differences in overall survival (median 8.2 vs 11.2 months; P = .2). Following inpatient admissions, early PC patients were more likely to be discharged home (59% vs 35%; P = .04). Conclusions: Timely PC consultations are advisable in this patient population and can reduce health-care utilization.

scholarly journals Practice Patterns, Attitudes, and Barriers to Palliative Care Consultation by Gynecologic Oncologists

2017 ◽  
Vol 13 (9) ◽  
pp. e703-e711 ◽  
Author(s):  
Alexandre Buckley de Meritens ◽  
Benjamin Margolis ◽  
Craig Blinderman ◽  
Holly G. Prigerson ◽  
Paul K. Maciejewski ◽  
...  
Keyword(s):  
Palliative Care ◽  
Practice Patterns ◽  
Medical Center ◽  
Symptom Control ◽  
Gynecologic Oncology ◽  
Academic Medical Center ◽  
Care Services ◽  
Palliative Care Consultation ◽  
Palliative Care Services ◽  
Care Consultation

Purpose: We sought to describe practice patterns, attitudes, and barriers to the integration of palliative care services by gynecologic oncologists. Methods: Members of the Society of Gynecologic Oncology were electronically surveyed regarding their practice of incorporating palliative care services and to identify barriers for consultation. Descriptive statistics were used, and two-sample z-tests of proportions were performed to compare responses to related questions. Results: Of the 145 respondents, 71% were attending physicians and 58% worked at an academic medical center. The vast majority (92%) had palliative care services available for consultation at their hospital; 48% thought that palliative care services were appropriately used, 51% thought they were underused, and 1% thought they were overused. Thirty percent of respondents thought that palliative care services should be incorporated at first recurrence, whereas 42% thought palliative care should be incorporated when prognosis for life expectancy is ≤ 6 months. Most participants (75%) responded that palliative care consultation is reasonable for symptom control at any stage of disease. Respondents were most likely to consult palliative care services for pain control (53%) and other symptoms (63%). Eighty-three percent of respondents thought that communicating prognosis is the primary team’s responsibility, whereas the responsibilities for pain and symptom control, resuscitation status, and goals of care discussions were split between the primary team only and both teams. The main barrier for consulting palliative care services was the concern that patients and families would feel abandoned by the primary oncologist (73%). Ninety-seven percent of respondents answered that palliative care services are useful to improve patient care. Conclusion: The majority of gynecologic oncologists perceived palliative care as a useful collaboration that is underused. Fear of perceived abandonment by the patient and family members was identified as a significant barrier to palliative care consult.

Impact of advance directive (AD) completion among patients with metastatic cancer treated at an academic medical center.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 114-114
Author(s):  
Nirav S. Kapadia ◽  
Jennifer Snide ◽  
Daniel J Gelb ◽  
Evelyn Schlosser
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advance Directive ◽  
Medical Center ◽  
Metastatic Cancer ◽  
Quality Care ◽  
Academic Medical Center ◽  
Life Quality ◽  
Cancer Center ◽  
Hospital Death

114 Background: Between February and September 2013, AD documentation for oncology patients across Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) increased from 36% to 48%. However, it remains unclear whether AD completion itself is associated with other indicators of quality care. Methods: Using the tumor registry and National Death Index patient data, we examined a cohort of deceased NCCC patients diagnosed with metastatic disease between April 1, 2011 and October 31, 2013. To account for unmeasured care provided outside of NCCC, only patients with at least two NCCC visits, one of which occurred within the last six months of life, were included. Individual patient electronic medical record data were then linked to the registry data and multivariable regression was performed to determine the effect of AD completion on end-of-life quality metrics. Results: The cohort consisted of 225 patients, 182 (81%) of whom had an advance directive on file and 43 (19%) who did not. There were no significant differences in the age, gender or cancer diagnosis between the two groups. Patients with an AD had shorter commutes to the medical center (mean 42 vs 58 minutes, p<0.01) and more visits with cancer center providers (median 11.5 vs. 4.0, p=0.03). Palliative Care consulted with 73% of patients with an AD, versus 28% of patients without an AD (p<0.01). Completion of an AD did not decrease the likelihood of hospital death (OR 0.90, 95% CI 0.33-2.49), intensive care unit (ICU) death (OR 0.83, 0.19-3.66), hospital admission in the last 30 days of life (OR 0.94, 0.40-2.21), or ICU admission in the last 30 days of life (OR 1.30, 0.37-4.55). Patients with an AD were twice as likely to receive hospice referrals (OR 2.04, 0.73-5.68) and 70% less likely to visit the emergency department in the last 30 days of life compared with patients without an AD on file (OR 0.28, 0.06-1.40), although these trends were not statistically significant. Conclusions: For patients with metastatic cancer, an advance directive was associated with increased use of palliative care, though not with other measures of quality care. In an attempt to improve the cancer care provided at the end of life, we must expand our strategies beyond the use of an AD.

Is screening enough? Implications of a pilot utilizing standard screening criteria for early palliative referral.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 119-119
Author(s):  
Kavitha Ramchandran ◽  
Marcy Winget ◽  
Erika L Tribett ◽  
Bev Anderson ◽  
Alison Morris ◽  
...  
Keyword(s):  
Palliative Care ◽  
Cancer Care ◽  
Palliative Medicine ◽  
Screening Tool ◽  
Medical Center ◽  
Gynecologic Oncology ◽  
Academic Medical Center ◽  
Care Needs ◽  
Early Integration ◽  
Nurse Navigator

119 Background: Early integration of palliative medicine (PM) into cancer care improves outcomes including quality of life, care coordination and survival. Despite broad endorsement and established guidelines for integration of PM into cancer care, patients are not routinely or comprehensively screened for PM needs. Misconceptions and biases about PM impede screening, uptake and access. A set protocol or triggers for PM may be able to overcome these barriers. This study evaluated the feasibility of using a basic screening protocol using NCCN criteria for automatic PM referral with nurse navigators in gynecologic oncology at one academic medical center. Methods: All patients attending the gynecologic oncology clinic at Stanford Cancer Institute between June 2014 and February 2015 with an assigned nurse navigator (n = 120) were screened for palliative medicine needs using the NCCN guidelines at their new patient visit. A one-page screening tool was developed and nurses were trained to make referrals to PM based on positive screen results. Chart reviews were conducted to identify the percent of new patients screened, the percent of patients who screened positive based on NCCN criteria, and the percent of patients referred to PM. Results: 50% of the cohort of patients were screened using the protocol. Less than 5% percent were referred to PM. However, chart review revealed that forty percent of all patients met NCCN criteria for referral to PM. Referrals to other support services based on screening included oncology social work and survivorship. Conclusions: Implementation of a standard screening tool is not sufficient to ensure that palliative care needs are assessed, and that appropriate referrals are made. Automated mechanisms to make screening facile, as well as algorithms for assessment and intervention are critical to ensure that patients unmet physical and psychosocial palliative needs are identified and treated. Additionally addressing barriers such as branding of palliative medicine, and education of staff on primary palliative care skills such as pain management and therapeutic communication may be strategies to incorporate going forward.

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