THE PLACE AND CONTENT OF PALLIATIVE CARE - cSlide
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THE PLACE AND CONTENT OF PALLIATIVE CARE
in a comprehensive cancer center in Europe the National
Cancer Institute of Milan
Augusto Caraceni
Director Palliative Care , Pain therapy and rehabilitation
Fondazione IRCCS Istituto Nazionale dei Tumori Milano
Chair European Association for Palliative Care Research Network
esmo.org
CONFLICT OF INTEREST DISCLOSURE i. - Personal financial interests, I received honoraria in the past 5 years from Italfaramco, Pierre Fabre , Sandoz and Molteni srl - Institutional financial interests, Research grants were paid to my Institution by Molteni and IPSEN
Palliative care at NCI Milano ◆ 1987 The denomination of the Pain Therapy and Rehabilitation Department was changed into ◆ Palliative care , pain therapy and rehabilitation
+ Palliative care at the National Cancer Institute
of Milan 2018
◆ Outpatient
◆ Three daily clinics (3 doctors, 30 to 40 patients per day ) Day Hospital ( 1 doctor 6-8
admissions per day)
◆ Inpatient hospice Unit
◆ (10 beds 1 doctor 18 nurses and nurse aids , + multidisciplinary team – 180-190 admissions
per year)
◆ Inpatients consult service
◆ (1 doctor 1 nurse, 500-600 new Consults per year )
◆ Home care team
◆ (4 doctors 5 nurses + multidisciplinary team 240-300 patients per year)Referral to Palliative
Care Clinic
Hannon et al Supp
Care Cancer 2015
Palliative Care Clinic
Consultation Early Palliative
Care
Longitudinal follow-up in tandem with oncology,
primary and community care for
• symptom control
• psychosocial care
• referral to community services
• advance care planning
Transitional and
Community Hospice In patient Home Palliative end of life care
Residential Hospice PC unit Care+
Indicators of Integration of oncology and palliative as represented in RCTs on
early palliative care and compared with the Milan program
Clinical structure Temel Zimmermann Maltoni NCI
2011 2014 2016 Milano
Palliative inpatient consult team y Y - Y
Palliative care outpatient clinic Y Y Y Y
Home palliative care - Y - Y
Kaasa et al Lancet Oncology In Press as modified from Hui et al 2015Clinical processes Temel Zimmermann Maltoni NCI
2011 2014 2016 Milano
Multidisciplinary specialized palliative care
team Y Y Y Y
Routine symptom screening in the
oncology clinic - - - -
Administration of anticancer therapy when
patients admitted to pc service Y Y Y Y
Follow palliative care guidelines Y - Y -
Kaasa et al Lancet Oncology In Press modified from Hui et al 2015Clinical processes Temel Zimmermann Maltoni NCI
2011 2014 2016 Milano
Early referral to palliative care Y Y Y Y
Availability of care pathways with
automatic trigger for PC referral - - - -
Palliative care team routinely involved in
multidisciplinary tumor conference/board Y - - -
Communication cooperation and
coordination between pc and oncology Y - Y ?
service
Routine discussion of prognosis advance
care planning with goals of care Y Y Y ?
Kaasa et al Lancet Oncology In Press modified from Hui et al 2015The outpatient clinic experience
Thoracic oncology palliative care clinic referral
• Two years follow up of Thoracic oncology clinic: 229 new patients directly
followed up in the clinic.
• 98 (43% 95% CI = 36-49%) were referred to Palliative Care clinic after a
median of 30 days from first visit
• The figures show median follow-up time in daysFactors associated with PC clinic referral at multivariate analyses ◆ Disease stage (III / IV) ◆ Pain ◆ Cough ◆ Brain metastases
Palliative care clinic history after referral
◆ 98 patients received a median of 5 visits (Range 2 – 11) , 1 every 9 days
◆ 80 patients received chemotherapy and PC simultaneously (median follow up 128
days)
◆ 25 patients were still alive after 2 years
◆ 65 died during the two years of study (median time interval from referral to
death128 days)
◆ 8 patients were lost to follow upUse of resources at the end of life for 65 patients who die after referral to PC
within the two year perido of study compared with RCTs on early palliative care
Use of resources NCI Milan Temel 2012 Maltoni 2016 Vanbutsele PhD
Thesis 2018
Hospice or home PC death 66% 80% 66% -
Hospital last 30 days/death 30% 20% 30% 60%
Chemotherapy last 30 days 14% 30% 18% 29%Key elements to specialized palliative care
Hoerger M et al
JCO 2018
FooterHow does specialized palliative care work ?
◆ Visits addressing coping are associated with improvement in QOL and
depression
◆ Visits addressing treatment decisions are associated with lower probability of
receiving chemotherapy or having a hospital admission in the last 60 days of life
◆ Visits addressing care planning are associated with higher probability of
receiving hospice care
Hoerger M et al JCO 2018
FooterHow to improve integration and missing points
◆ Structure
◆ Palliative care services
◆ Care pathways
◆ E.g. test criteria for early referral to PC
◆ Policy
◆ “Palliative is care not perceived as integral part of cancer care continuum “
(Kaasa et al Lancet Oncology 2018)
◆ Research
◆ EducationLancet Oncology 2016
Need based criteria
◆ Severe physical symptoms Psychosocial criteria
• Young age presence of young children
◆ Severe emotional symptoms • Difficult family situations
◆ Request for hastened death
◆ Spiritual or existential crisis
◆ Assistance with decision making or care planning
◆ Patient request
◆ Delirium
◆ Leptomeningean , brain met spinal cord compression
Hui et al Lancet Oncology 2016The parents of a young woman with sarcoma admitted to hospice
at NCI where she died wrote :
◆ Da voi abbiamo potuto vedere salvaguardata la ◆ With you we could see the dignity of our young
dignità della nostra giovane donna , e messo in woman defended and her right to palliative care
pratica il suo diritto a cure palliative che riducessero put into practice in order to relieve her physical
per quanto possibile le sue sofferenze fisiche e
psicologiche, nel rispetto della deontologia
and psychological suffering, respecting
professionale ma anche senza accanimento professional standards, but also avoiding
terapeutico. Siamo stati circondati dalla sollecitudine overtreatment. We have been surrounded by
di tutto il Personale Medico Infermieristico e Ausiliario, the sollicitous help of the medical , nursing ,
nonché dai volontari . Così , in quel drammatico nursing-aid staff and by volunteers. Therefore,
periodo abbiamo potuto ricreare all’ interno in that dramatic period of time, we were able to
dell’hospice l’ultima possibile forma di vita familiare. E build within the hospice the last possible way to
ricevere il quotidiano supporto dei nostri familiari ed
amici adulti, e soprattutto di quella splendida pattuglia
family life. We were able to receive the daily
di irriducibili amici di G che insieme a Voi l’hanno support of our family and friends and above all
sostenuta letteralmente sino Rall’ultimo respiro of that indomitable squad of G’s friends who
together with You supported her literarily till the
very last breath.jjj
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