- Email: [email protected]
A Multidisciplinary Approach for Bone Metastases
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Schedule with Abstracts
Domain Physical Aspects of Care
Prognostic Significance of the Surprise Question in Cancer Patients Alvin Moss, MD FAAHPM, West Virginia University, Morgantown, WV. June Lunney, PhD RN, West Virginia University, Morgantown, WV. Stacey Culp, PhD, West Virginia University, Morgantown, WV. James Abraham, MD FACP, West Virginia University, Morgantown, WV. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Discuss the use of the surprise question. 2. Describe outcomes with the use of the surprise question in cancer patient care. I. Background. Failure to estimate and communicate prognosis can lead to overly aggressive treatment for advanced cancer patients at the end-of-life. The surprise question ‘‘Would I be surprised if this patient died in the next year?’’ has been recognized as an innovation to improve end-of-life care in the primary care and dialysis populations by identifying patients with a poor prognosis who are appropriate for palliative care. The use of the surprise question to identify cancer patients with a poor prognosis has not been previously assessed. II. Research Objectives. To determine the feasibility and outcomes of the use of the surprise question in a cancer patient population. III. Methods. Oncologists prospectively classified consecutive breast, lung, and colon cancer patients into ‘‘Yes, I would be surprised’’ and ‘‘No, I would not be surprised’’ groups based on the surprise question. Patients were followed and their status at 1 yeardalive or deaddwas determined along with patient demographics, type of cancer, and stage at presentation. IV. Results. Oncologists classified 826 of 853 cancer patients (97%) with 131 (16%) classified into the No group and 695 (84%) into the Yes group. At 12 months, 71 patients had died (8.3%); 41% of the No patients had died compared to 3% of the Yes patients (P < .001). V. Conclusion. The surprise question is a simple, feasible, and effective tool to identify cancer patients with a greatly increased risk of 1-year mortality. VI. Implications for Research, Policy, or Practice. Palliative care clinicians should encourage
Vol. 39 No. 2 February 2010
oncologists to use the surprise question to identify patients appropriate for palliative care referral. Further research is necessary to determine if use of the surprise question leads to improved patient care outcomes. Domain Structure and Processes of Care
A Multidisciplinary Approach for Bone Metastases Masanori Mori, MD, Fletcher Allen Health Care, Burlington, VT. Christina Brus, MD, Yale University, New Haven, CT. Avnish Bhatia, MD, Jefferson Medical College, Philadelphia, PA. Taiga Nishihori, MD, Yale University, New Haven, CT. Ronald Blum, MD, Beth Israel Medical Cancer Center, New York, NY. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Describe the multidisciplinary approach for cancer patients with newly diagnosed bone metastases. 2. Utilize the bone metastasis clinical pathway in the management of patients with metastatic bone disease. I. Background. A multidisciplinary approach has been advocated to improve quality of life and decrease complications from skeletal metastasis. In the June 2003 issue of Oncology, Blum et al. showed a clinical pathway that was developed at Beth Israel Medical Center in New York to guide the multidisciplinary decision-making processes for assessing and managing skeletal metastases. II. Research Objectives. To demonstrate the feasibility of managing patients with metastatic bone disease utilizing the bone metastasis clinical pathway. III. Methods. We performed a prospective, IRB approved, case-based chart-review study of cancer patients with radiographic evidence of new or progressive bone metastases from January 2005 to January 2008 at Beth Israel Medical Center. The feasibility of using the clinical pathway was assessed by evaluating the compliance of patients to the clinical pathway guidelines and examining the reasons for deviation. The primary endpoints are: total compliance (at least 75% adherence to the overall decision points of the clinical pathway guidelines); partial compliance (at least 50% adherence); and noncompliance (less than 50% adherence).
Vol. 39 No. 2 February 2010
Schedule with Abstracts
IV. Results. Fifteen patients were enrolled in the study with the following diagnoses: prostate cancer (5 patients); breast cancer (2); and lung cancer (2). One patient had each of these diagnoses: cholangiocarcinoma; colon cancer; renal cell carcinoma; laryngeal cancer; non-Hodgkin lymphoma; multiple myeloma. Out of 15 patients, total compliance was achieved by 14 (93%), with 9 patients (60%) adhered to 100% of the decision points of the pathway. One patient (6.7%) demonstrated 50% adherence, and thus exhibited only partial compliance. No one demonstrated noncompliance. V. Conclusion. This prospective validation study has demonstrated the feasibility of using the bone metastasis clinical pathway in the management of patients with a large diversity of primary tumors. VI. Implications for Research, Policy, or Practice. This pathway provides a practical way of implementing and systematizing a multidisciplinary effort to improve clinical outcomes. Domains Structure and Processes of Care; Physical Aspects of Care
Paper Session (308) My IV Drip or Me? Death from Heart Failure in an Inpatient Hospice Facility Gwen Dodson, MSN ANP, Duke University, Durham, NC. Toni Cutson, MD MHS, Duke University Durham VAMC, Durham, NC. Jennifer Gentry, MSN APRN BC, Duke University Medical Center, Durham, NC. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Describe important issues in caring for endstage heart failure patients. 2. Discuss important considerations in the use of inotropic therapy in a hospice setting. I. Background. Heart failure (HF) has been referred to by some as America’s silent epidemic. HF death rates remain high with many patients succumbing within 5 years of diagnosis. The silence and lack of emphasis given this patient population is an important topic for hospice and palliative care professionals. As with any epidemic, valiant attempts have been made to prolong and improve quality of life. In the case of end-stage heart failure, the focus is on the
347
addition of inotrope therapy, often during the patient’s final hospital stay. With the ability to discharge HF patients from the hospital on intravenous (IV) inotropes, a new conundrum has emerged: when to wean and/or stop the drip. Experiences gained in caring for these patients have revealed that the psychological impact of this therapy has changed the patient and families view of both living and dying. During a 12-month period, one inpatient hospice facility has had the experience of caring for six end-stage HF patients receiving inotrope therapy. An overwhelming focus for the patients and their families has been the IV drip. The hospice staff has faced many unique challenges in caring for patients receiving inotropes both in the acquisition of new technical skills and in helping patients make a peaceful transition. Using several case studies, the care of the patient receiving inotrope therapy in a hospice setting will be explored. II. Case Description. A case series of end-stage HF patients on inotropes admitted to an inpatient hospice facility. After inpatient hospice admission, discussions involve weaning or maintaining the IV drip while supporting the patient and family through the final days and weeks. III. Conclusion. Focus on living and goal setting rather than monitoring the inotrope therapy. Further education regarding inotrope therapy is needed along all points of the trajectory from hospital setting to hospice. Domains Structure and Processes of Care; Physical Aspects of Care; Psychological Aspects of Care; Social Aspects of Care
Noncancer Pain and Cognitive Impairment: A Disabling Relationship? Joseph Shega, MD, University of Chicago, Chicago, IL, Judith Paice, PhD RN, Northwestern University, Chicago, IL. Kenneth Rockwood, MD, University of Chicago, Chicago, IL. William Dale, MD PhD, University of Chicago, Chicago, IL. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Identify the contribution of noncancer pain and cognitive impairment with functional disability among community-dwelling older adults. 2. Discuss whether or not noncancer pain and cognitive impairment display a nonlinear relationship with functional disability.
Schedule with Abstracts
Domain Physical Aspects of Care
Prognostic Significance of the Surprise Question in Cancer Patients Alvin Moss, MD FAAHPM, West Virginia University, Morgantown, WV. June Lunney, PhD RN, West Virginia University, Morgantown, WV. Stacey Culp, PhD, West Virginia University, Morgantown, WV. James Abraham, MD FACP, West Virginia University, Morgantown, WV. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Discuss the use of the surprise question. 2. Describe outcomes with the use of the surprise question in cancer patient care. I. Background. Failure to estimate and communicate prognosis can lead to overly aggressive treatment for advanced cancer patients at the end-of-life. The surprise question ‘‘Would I be surprised if this patient died in the next year?’’ has been recognized as an innovation to improve end-of-life care in the primary care and dialysis populations by identifying patients with a poor prognosis who are appropriate for palliative care. The use of the surprise question to identify cancer patients with a poor prognosis has not been previously assessed. II. Research Objectives. To determine the feasibility and outcomes of the use of the surprise question in a cancer patient population. III. Methods. Oncologists prospectively classified consecutive breast, lung, and colon cancer patients into ‘‘Yes, I would be surprised’’ and ‘‘No, I would not be surprised’’ groups based on the surprise question. Patients were followed and their status at 1 yeardalive or deaddwas determined along with patient demographics, type of cancer, and stage at presentation. IV. Results. Oncologists classified 826 of 853 cancer patients (97%) with 131 (16%) classified into the No group and 695 (84%) into the Yes group. At 12 months, 71 patients had died (8.3%); 41% of the No patients had died compared to 3% of the Yes patients (P < .001). V. Conclusion. The surprise question is a simple, feasible, and effective tool to identify cancer patients with a greatly increased risk of 1-year mortality. VI. Implications for Research, Policy, or Practice. Palliative care clinicians should encourage
Vol. 39 No. 2 February 2010
oncologists to use the surprise question to identify patients appropriate for palliative care referral. Further research is necessary to determine if use of the surprise question leads to improved patient care outcomes. Domain Structure and Processes of Care
A Multidisciplinary Approach for Bone Metastases Masanori Mori, MD, Fletcher Allen Health Care, Burlington, VT. Christina Brus, MD, Yale University, New Haven, CT. Avnish Bhatia, MD, Jefferson Medical College, Philadelphia, PA. Taiga Nishihori, MD, Yale University, New Haven, CT. Ronald Blum, MD, Beth Israel Medical Cancer Center, New York, NY. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Describe the multidisciplinary approach for cancer patients with newly diagnosed bone metastases. 2. Utilize the bone metastasis clinical pathway in the management of patients with metastatic bone disease. I. Background. A multidisciplinary approach has been advocated to improve quality of life and decrease complications from skeletal metastasis. In the June 2003 issue of Oncology, Blum et al. showed a clinical pathway that was developed at Beth Israel Medical Center in New York to guide the multidisciplinary decision-making processes for assessing and managing skeletal metastases. II. Research Objectives. To demonstrate the feasibility of managing patients with metastatic bone disease utilizing the bone metastasis clinical pathway. III. Methods. We performed a prospective, IRB approved, case-based chart-review study of cancer patients with radiographic evidence of new or progressive bone metastases from January 2005 to January 2008 at Beth Israel Medical Center. The feasibility of using the clinical pathway was assessed by evaluating the compliance of patients to the clinical pathway guidelines and examining the reasons for deviation. The primary endpoints are: total compliance (at least 75% adherence to the overall decision points of the clinical pathway guidelines); partial compliance (at least 50% adherence); and noncompliance (less than 50% adherence).
Vol. 39 No. 2 February 2010
Schedule with Abstracts
IV. Results. Fifteen patients were enrolled in the study with the following diagnoses: prostate cancer (5 patients); breast cancer (2); and lung cancer (2). One patient had each of these diagnoses: cholangiocarcinoma; colon cancer; renal cell carcinoma; laryngeal cancer; non-Hodgkin lymphoma; multiple myeloma. Out of 15 patients, total compliance was achieved by 14 (93%), with 9 patients (60%) adhered to 100% of the decision points of the pathway. One patient (6.7%) demonstrated 50% adherence, and thus exhibited only partial compliance. No one demonstrated noncompliance. V. Conclusion. This prospective validation study has demonstrated the feasibility of using the bone metastasis clinical pathway in the management of patients with a large diversity of primary tumors. VI. Implications for Research, Policy, or Practice. This pathway provides a practical way of implementing and systematizing a multidisciplinary effort to improve clinical outcomes. Domains Structure and Processes of Care; Physical Aspects of Care
Paper Session (308) My IV Drip or Me? Death from Heart Failure in an Inpatient Hospice Facility Gwen Dodson, MSN ANP, Duke University, Durham, NC. Toni Cutson, MD MHS, Duke University Durham VAMC, Durham, NC. Jennifer Gentry, MSN APRN BC, Duke University Medical Center, Durham, NC. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Describe important issues in caring for endstage heart failure patients. 2. Discuss important considerations in the use of inotropic therapy in a hospice setting. I. Background. Heart failure (HF) has been referred to by some as America’s silent epidemic. HF death rates remain high with many patients succumbing within 5 years of diagnosis. The silence and lack of emphasis given this patient population is an important topic for hospice and palliative care professionals. As with any epidemic, valiant attempts have been made to prolong and improve quality of life. In the case of end-stage heart failure, the focus is on the
347
addition of inotrope therapy, often during the patient’s final hospital stay. With the ability to discharge HF patients from the hospital on intravenous (IV) inotropes, a new conundrum has emerged: when to wean and/or stop the drip. Experiences gained in caring for these patients have revealed that the psychological impact of this therapy has changed the patient and families view of both living and dying. During a 12-month period, one inpatient hospice facility has had the experience of caring for six end-stage HF patients receiving inotrope therapy. An overwhelming focus for the patients and their families has been the IV drip. The hospice staff has faced many unique challenges in caring for patients receiving inotropes both in the acquisition of new technical skills and in helping patients make a peaceful transition. Using several case studies, the care of the patient receiving inotrope therapy in a hospice setting will be explored. II. Case Description. A case series of end-stage HF patients on inotropes admitted to an inpatient hospice facility. After inpatient hospice admission, discussions involve weaning or maintaining the IV drip while supporting the patient and family through the final days and weeks. III. Conclusion. Focus on living and goal setting rather than monitoring the inotrope therapy. Further education regarding inotrope therapy is needed along all points of the trajectory from hospital setting to hospice. Domains Structure and Processes of Care; Physical Aspects of Care; Psychological Aspects of Care; Social Aspects of Care
Noncancer Pain and Cognitive Impairment: A Disabling Relationship? Joseph Shega, MD, University of Chicago, Chicago, IL, Judith Paice, PhD RN, Northwestern University, Chicago, IL. Kenneth Rockwood, MD, University of Chicago, Chicago, IL. William Dale, MD PhD, University of Chicago, Chicago, IL. (All speakers have disclosed no relevant financial relationships.) Objectives 1. Identify the contribution of noncancer pain and cognitive impairment with functional disability among community-dwelling older adults. 2. Discuss whether or not noncancer pain and cognitive impairment display a nonlinear relationship with functional disability.