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Making My Course Better: Using Patient Reported Outcomes to Integrate Palliative Care Acrossthe Spectrum of Care for Patients with Advanced Cancer (FR417)
Vol. 47 No. 2 February 2014
Schedule With Abstracts
2. Highlight the unique features of creative arts therapy in pediatrics in defining meaning, relieving distress, making memories, and bereavement. 3. Demonstrate live, audio, and visual therapy projects across practice settings that include adolescent and perinatal projects and co-treating with multidisciplinary therapies, including occupational and physical therapy, and therapeutic recreation. A music therapist and two pediatric palliative physicians will present a review of the evidence supporting the use of creative arts therapies in the care of the pediatric patient. The difficulties of supporting young patients with life-threatening illnesses are to be explained. Engaging children and adolescents with life-threatening illness in supportive dialogue is challenging for providers and caregivers. Expressions of joy, regret, angst, and grief are difficult for pediatric patients as well as discussions of goals and priorities. However, the creative arts provide an effective conduit for these individual expressions. By permitting and exploring these expressions, physical and emotional distress is relieved. For parents and siblings, creative arts therapies are unique in defining meaning and memorymaking. This will be followed by a demonstration of several creative arts therapy projects in audio and video format. Portions of these demonstrations will include live music therapy interventions. These projects occur in home and inpatient settings. The subjects are expectant parents in a perinatal palliative program, school aged children, and adolescents/young adults. The projects demonstrate individualized approaches consistent with unique identities of the patients.
Making My Course Better: Using Patient Reported Outcomes to Integrate Palliative Care Acrossthe Spectrum of Care for Patients with Advanced Cancer (FR417) Leslie Blackhall, MD MTS, University of Virginia School of Medicine, Charlottesville, VA. Paul Read University of Virginia School of Medicine, Charlottesville, VA. MaryAnn Davis University of Virginia School of Medicine, Charlottesville, VA. George Stukenborg, PhD MA, University of Virginia School of Medicine, Charlottesville, VA. (All authors listed above had no relevant financial relationships to disclose.)
425
Objectives 1. Identify ways to integrate patient-reported outcomes measuring symptoms and functional status into the electronic medical record, where they can be tracked over time and used as a basis for clinical decision making in cancer care. 2. Discuss effective methods of integrating palliative and supportive care interventions into standard outpatient cancer care. 3. Understand the impact of rapid palliative radiation on pain and functional status for patients with bone metastasis. As a result of data indicating that combining palliative care with standard cancer care leads to better patient outcomes, the Society of Clinical Oncologists has endorsed a concurrent care model. The characteristics of effective collaboration and best ways to utilize palliative care resources in this setting require further study. ‘‘Making My Course Better,’’ a project at the University of Virginia (funded through a Centers for Medicare & Medicaid Services Innovation Award) seeks to improve patient care through the frequent monitoring of symptoms and functional status, improved care-coordination, and early intervention with palliative care referral and state-of-the-art treatments for troubling symptoms. We will measure effects of this phased intervention on clinical outcomes, such as control of cancer-related symptoms, timing of hospice referral, and chemotherapy in the last 14 days of life. Components of this intervention include: MY Course: a dashboard of patient-reported outcomes (including functional status, pain, depression, nausea, and fatigue), completed by patients at each visit and integrated into the electronic medical record, where change in symptom severity over time can be tracked. Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track): a tool utilizing My Course data to trigger case review at Supportive Care Tumor Board (SCTB), a multidisciplinary group of oncologists, palliative care clinicians, and other professionals, where interventions such as referral to palliative care, STAT Rad, anesthesia pain, or other supportive services can be discussed. Interactive displays of My Course data will be used at SCTBto examine the effect of interventions
426
Schedule With Abstracts
on symptoms and to suggest timing of transition from active treatment to hospice. STAT Rad: Patients with increasing pain because of bone metastasis will be eligible for this palliative radiation intervention, which transforms 2-3 week workflows to a single noninvasive treatment. The My Course PRO system for patient care will be demonstrated during this presentation, using longitudinal case studies, along with preliminary outcome data.
Death by Chocolate: How to Palliate to Dysphagia (FR418) Mary Buss, MD, Beth Israel Deaconess Medical Center, Boston, MA. Amanda Warren, MS CCCSLP, Beth Israel Deaconess Medical Center, Boston, MA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Determine the best approach for evaluating dysphagia, focusing on when subjective bedside swallowing studies are adequate and when more objective measures are needed. 2. Prescribe palliative management strategies for dysphagia, such as: oral care, oral supplements, diet consistency, and diet administration modifications. 3. Address the concerns of family and staff who must witness the sequelae of eating in patient with dysphagia. Dysphagia is highly prevalent, with as many as one in five patients older than 50 years experiencing it. Palliative care teams are frequently called upon to help patients, families, and referring providers weigh the risks and benefits of pursuing artificial nutrition, such as a gastrostomy tube or total parenteral nutrition. Palliative care specialists, supported by a considerable literature, often recommend or support decisions against the placement of tubes to supplement or replace oral nutrition, yet many of these same palliative care clinicians offer no concrete recommendations to help manage patients who have dysphagia and elect to eat. If the medical team and swallowing therapists understand the goal as palliation of dysphagia, rather than the prevention of aspiration, the approach and recommendations change considerably. Using the case a feisty older woman who loved chocolate, we will discuss a palliative approach to the diagnostic work-up and the management of
Vol. 47 No. 2 February 2014
dysphagia. First, we will provide a framework for assessing the benefits and burdens of various diagnostic procedures. The advantages and limitations of bedside swallowing exams will be reviewed and compared with other approaches, such as a modified barium swallow. When patients with dysphagia wish to continue eating, there are strategies that a swallowing therapist can implement to reduce discomfort and increase quality of life. We will explore alternatives, including changing diet consistencies, modifying administration methods for oral intake, providing oral supplements, and the importance of excellent oral care in reducing risk for aspiration pneumonia. Watching patients with dysphagia eat can provoke strong emotions for family and professional caregivers, who may feel they are encouraging behavior that leads to patient suffering or harm. We suggest strategies promoting careful interdisciplinary communication to ensure that all team members can comfortably support patients in choices to continue eating.
Decision-Making Capacity: What Is It? Who Decides If Your Patient Has It? (FR419) Randy Schisler, MD, Carolinas Medical CenterNortheast, Concord, NC. Maureen Link, ANCC-BC, Carolinas Healthcare System, Charlotte, NC. Erica Frechman, A/GNP-BC ACHPN, Carolinas Healthcare System, Charlotte, NC. Andrea Wever, JD MPH, Carolinas Healthcare System, Charlotte, NC. David Klein, MD, Georgia Regional Hospital, Decatur, GA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Have a better understanding of decisionmaking capacity and how to assess it in patients. 2. Recognize those patients for whom the palliative care provider can determine capacity versus those who require formal neuropsychiatric consultation. 3. Understand possible legal implications with decision-making capacity assessments and where to go for additional information The Palliative Medicine consultant promotes respect for the ethical principle of autonomy, provides education on the Patient Self-Determination Act through advanced care planning and living wills, and explores end-of-life preferences based on a patient’s own values. However, the ability to provide informed consent, a
Schedule With Abstracts
2. Highlight the unique features of creative arts therapy in pediatrics in defining meaning, relieving distress, making memories, and bereavement. 3. Demonstrate live, audio, and visual therapy projects across practice settings that include adolescent and perinatal projects and co-treating with multidisciplinary therapies, including occupational and physical therapy, and therapeutic recreation. A music therapist and two pediatric palliative physicians will present a review of the evidence supporting the use of creative arts therapies in the care of the pediatric patient. The difficulties of supporting young patients with life-threatening illnesses are to be explained. Engaging children and adolescents with life-threatening illness in supportive dialogue is challenging for providers and caregivers. Expressions of joy, regret, angst, and grief are difficult for pediatric patients as well as discussions of goals and priorities. However, the creative arts provide an effective conduit for these individual expressions. By permitting and exploring these expressions, physical and emotional distress is relieved. For parents and siblings, creative arts therapies are unique in defining meaning and memorymaking. This will be followed by a demonstration of several creative arts therapy projects in audio and video format. Portions of these demonstrations will include live music therapy interventions. These projects occur in home and inpatient settings. The subjects are expectant parents in a perinatal palliative program, school aged children, and adolescents/young adults. The projects demonstrate individualized approaches consistent with unique identities of the patients.
Making My Course Better: Using Patient Reported Outcomes to Integrate Palliative Care Acrossthe Spectrum of Care for Patients with Advanced Cancer (FR417) Leslie Blackhall, MD MTS, University of Virginia School of Medicine, Charlottesville, VA. Paul Read University of Virginia School of Medicine, Charlottesville, VA. MaryAnn Davis University of Virginia School of Medicine, Charlottesville, VA. George Stukenborg, PhD MA, University of Virginia School of Medicine, Charlottesville, VA. (All authors listed above had no relevant financial relationships to disclose.)
425
Objectives 1. Identify ways to integrate patient-reported outcomes measuring symptoms and functional status into the electronic medical record, where they can be tracked over time and used as a basis for clinical decision making in cancer care. 2. Discuss effective methods of integrating palliative and supportive care interventions into standard outpatient cancer care. 3. Understand the impact of rapid palliative radiation on pain and functional status for patients with bone metastasis. As a result of data indicating that combining palliative care with standard cancer care leads to better patient outcomes, the Society of Clinical Oncologists has endorsed a concurrent care model. The characteristics of effective collaboration and best ways to utilize palliative care resources in this setting require further study. ‘‘Making My Course Better,’’ a project at the University of Virginia (funded through a Centers for Medicare & Medicaid Services Innovation Award) seeks to improve patient care through the frequent monitoring of symptoms and functional status, improved care-coordination, and early intervention with palliative care referral and state-of-the-art treatments for troubling symptoms. We will measure effects of this phased intervention on clinical outcomes, such as control of cancer-related symptoms, timing of hospice referral, and chemotherapy in the last 14 days of life. Components of this intervention include: MY Course: a dashboard of patient-reported outcomes (including functional status, pain, depression, nausea, and fatigue), completed by patients at each visit and integrated into the electronic medical record, where change in symptom severity over time can be tracked. Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track): a tool utilizing My Course data to trigger case review at Supportive Care Tumor Board (SCTB), a multidisciplinary group of oncologists, palliative care clinicians, and other professionals, where interventions such as referral to palliative care, STAT Rad, anesthesia pain, or other supportive services can be discussed. Interactive displays of My Course data will be used at SCTBto examine the effect of interventions
426
Schedule With Abstracts
on symptoms and to suggest timing of transition from active treatment to hospice. STAT Rad: Patients with increasing pain because of bone metastasis will be eligible for this palliative radiation intervention, which transforms 2-3 week workflows to a single noninvasive treatment. The My Course PRO system for patient care will be demonstrated during this presentation, using longitudinal case studies, along with preliminary outcome data.
Death by Chocolate: How to Palliate to Dysphagia (FR418) Mary Buss, MD, Beth Israel Deaconess Medical Center, Boston, MA. Amanda Warren, MS CCCSLP, Beth Israel Deaconess Medical Center, Boston, MA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Determine the best approach for evaluating dysphagia, focusing on when subjective bedside swallowing studies are adequate and when more objective measures are needed. 2. Prescribe palliative management strategies for dysphagia, such as: oral care, oral supplements, diet consistency, and diet administration modifications. 3. Address the concerns of family and staff who must witness the sequelae of eating in patient with dysphagia. Dysphagia is highly prevalent, with as many as one in five patients older than 50 years experiencing it. Palliative care teams are frequently called upon to help patients, families, and referring providers weigh the risks and benefits of pursuing artificial nutrition, such as a gastrostomy tube or total parenteral nutrition. Palliative care specialists, supported by a considerable literature, often recommend or support decisions against the placement of tubes to supplement or replace oral nutrition, yet many of these same palliative care clinicians offer no concrete recommendations to help manage patients who have dysphagia and elect to eat. If the medical team and swallowing therapists understand the goal as palliation of dysphagia, rather than the prevention of aspiration, the approach and recommendations change considerably. Using the case a feisty older woman who loved chocolate, we will discuss a palliative approach to the diagnostic work-up and the management of
Vol. 47 No. 2 February 2014
dysphagia. First, we will provide a framework for assessing the benefits and burdens of various diagnostic procedures. The advantages and limitations of bedside swallowing exams will be reviewed and compared with other approaches, such as a modified barium swallow. When patients with dysphagia wish to continue eating, there are strategies that a swallowing therapist can implement to reduce discomfort and increase quality of life. We will explore alternatives, including changing diet consistencies, modifying administration methods for oral intake, providing oral supplements, and the importance of excellent oral care in reducing risk for aspiration pneumonia. Watching patients with dysphagia eat can provoke strong emotions for family and professional caregivers, who may feel they are encouraging behavior that leads to patient suffering or harm. We suggest strategies promoting careful interdisciplinary communication to ensure that all team members can comfortably support patients in choices to continue eating.
Decision-Making Capacity: What Is It? Who Decides If Your Patient Has It? (FR419) Randy Schisler, MD, Carolinas Medical CenterNortheast, Concord, NC. Maureen Link, ANCC-BC, Carolinas Healthcare System, Charlotte, NC. Erica Frechman, A/GNP-BC ACHPN, Carolinas Healthcare System, Charlotte, NC. Andrea Wever, JD MPH, Carolinas Healthcare System, Charlotte, NC. David Klein, MD, Georgia Regional Hospital, Decatur, GA. (All authors listed above had no relevant financial relationships to disclose.) Objectives 1. Have a better understanding of decisionmaking capacity and how to assess it in patients. 2. Recognize those patients for whom the palliative care provider can determine capacity versus those who require formal neuropsychiatric consultation. 3. Understand possible legal implications with decision-making capacity assessments and where to go for additional information The Palliative Medicine consultant promotes respect for the ethical principle of autonomy, provides education on the Patient Self-Determination Act through advanced care planning and living wills, and explores end-of-life preferences based on a patient’s own values. However, the ability to provide informed consent, a