Huge Progress in Palliative Care

A Q&A with Diane E. Meier, MD, FACP, Director, Center to Advance Palliative Care; Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai; New York, NY; diane.meier@mssm.edu

Originally published November 8, 2017

Q: You wrote in MedGenMed in 2007 that palliative care was the job of all hospitals. In October 2017 you were honored at the National Academy of Medicine for your achievements in this field. How fully has your charge to hospitals in 2007 been realized?

A: Palliative care is a fairly new medical specialty devoted to reducing suffering and improving quality of life for people living with serious illness-whether the disease is curable, chronic, or life threatening and progressive. Palliative care teams work alongside disease treatment specialists to provide an added layer of support in service of pain and symptom management, family support, attention to the social determinants of health, and skilled communication about what to expect and what matters most to the patient in the context of the reality of the illness. Multiple studies demonstrate palliative care’s contribution to achievement of the triple aim: better experience of care, better care outcomes (including survival in several studies), and as an epiphenomenon of better care, much lower unnecessary utilization of 911 calls, ED visits, and hospitalization. Continue reading…


Hospice Care Lowers Cost and ICU Use in Cancer Patients

“Hospice care at the end of life can significantly lower rates of hospitalization, intensive care unit (ICU) admission, and invasive procedures for cancer patients, according to a new study. Not surprisingly, it can also significantly lower healthcare costs.

“The study, which was published in the November 12 issue ofJAMA, adds further evidence to research that has shown that hospice care can reduce aggressive medical interventions and healthcare costs.

“The researchers, led by Ziad Obermeyer, MD, MPhil, from Brigham and Women’s Hospital and Harvard Medical School in Boston, looked at poor-prognosis cancers (lung, brain, pancreatic, any metastatic or ill-defined malignancy, and hematologic malignancies designated as relapsed or not in remission). They compared the use and costs of healthcare in Medicare patients who received hospice care and in those who did not.

“From a national sample of Medicare fee-for-service beneficiaries who died in 2011, the team identified 86,851 patients with poor-prognosis cancers, 60% of whom entered hospice before death.


Hospice Symptom Management System Benefited Patients, Caregivers

“A telephone-based symptom monitoring and coaching system improved patient symptoms and their caregiver’s well-being during hospice care, according to study results presented at the Palliative Care in Oncology Symposium.

“ ‘Within hospice care, there is this important triad that is made up of the hospice nurse, the dying patient and the family caregiver,’ researcher Bob Wong, PhD, director of applied statistics and research associate professor at the University of Utah College of Nursing, said during a press conference. ‘This study differs from many studies in the past that have focused on either the patient or just the caregiver themselves.’

“The analysis included 319 families who were receiving hospice care. Wong and colleagues assigned 153 families to the automated telephone symptom monitoring system. The other 166 patients received usual care.

“Caregivers from all the families called into the monitoring system daily to report the patient’s symptoms — including pain, difficulty breathing, change in thinking, constipation or diarrhea, bladder difficulties, nausea/vomiting, fatigue/weakness, negative mood, anxiety, trouble sleeping and poor appetite — from the previous 24 hours. The caregivers also were asked about their own fatigue, anxiety, sleep and mood.

“Families who were assigned the intervention then received automated coaching suggestions to address the symptoms of the patient and caregiver, and reports on unrelieved symptoms were sent to the hospice nurse.”


Study Reveals Profile of Patients Most Likely to Delay Hospice Enrollment Until Final Days of Life

” ‘Waiting until the final days of life to begin hospice can shortchange patients and their families — skipping over many benefits of hospice care and limiting the opportunity to improve patients’ quality of life during this stressful time,’ said study co-author David Casarett, MD, a professor of Medicine and director of Hospice and Palliative care at Penn Medicine. ‘Our findings point to some reasons why patients may seek hospice care so late in the course of their illness, which we hope will enable us to improve transitions to hospice at a more beneficial point in their care.’

“The team examined de-identified data from electronic medical records of 64,264 patients in 12 hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network from January 2008 to May 2013. Hospices spanned 11 states, including Pennsylvania, with censuses ranging from 400 to 1,700 patients per day. Of those 64,264 patients, 10,460 had a hospice stay of 3 days or fewer.

“The study found several characteristics associated with hospice length of stay of three days or less, including being male, married, younger than 65, and of nonwhite ethnicity. Also, patients with blood cancers and liver cancer were more often than those of oral cancer to be among those admitted within the last three days of life.”


Living With Cancer: A Tour of Hospice

“Before the visit, I had been split in two not by fear of death but by dread of dying — in anxiety, dementia, but mostly in pain from recurrent ovarian cancer.

“My mind was always running on two tracks. On one track, I attended to whatever actual event was occurring, be it an outing to the library or the making of a meal. The simultaneous second track was psychic or psychotic, depending on your point of view, but invariably chilling. It took me to scenes of the degeneration that would ensue after the targeted drug I am taking stopped working.

“So I welcomed the idea suggested by a member of my cancer support group: that we tour the new hospice facility where our friend Leslie had died. “Not a recruitment visit, just a field trip,” we joked as we decided to invite our partners to join us in meeting with the co-director of Hospice House, Dr. Robert Stone.

“On a fearfully cold day, we drove to a lodge on a wooded lot at the edge of our small town. By a blazing fireplace surrounded by comfortable chairs, about 10 of us amassed — six women dealing with gynecological cancer and some of our husbands. We were quiet because the family of a patient was using the adjacent kitchen.”

Image: iStock


Palliative Chemotherapy: Harms and Benefits Weighed in New Study

“Palliative chemotherapy is treatment designed for terminal cancer patients to prolong survival and ease symptoms but not cure disease. Now, researchers have found that the therapy comes with certain harms, which they say need to be addressed…

“Overall, the team found that terminal cancer patients who receive chemotherapy during the last months of their lives are less likely to die where they wish and are more likely to undergo invasive medical procedures – including CPR and mechanical ventilation – than patients who did not receive the therapy.”


Palliative Chemotherapy: Harms and Benefits Weighed in New Study

“Palliative chemotherapy is treatment designed for terminal cancer patients to prolong survival and ease symptoms but not cure disease. Now, researchers have found that the therapy comes with certain harms, which they say need to be addressed…

“Overall, the team found that terminal cancer patients who receive chemotherapy during the last months of their lives are less likely to die where they wish and are more likely to undergo invasive medical procedures – including CPR and mechanical ventilation – than patients who did not receive the therapy.”


Palliative Chemotherapy: Harms and Benefits Weighed in New Study

“Palliative chemotherapy is treatment designed for terminal cancer patients to prolong survival and ease symptoms but not cure disease. Now, researchers have found that the therapy comes with certain harms, which they say need to be addressed…

“Overall, the team found that terminal cancer patients who receive chemotherapy during the last months of their lives are less likely to die where they wish and are more likely to undergo invasive medical procedures – including CPR and mechanical ventilation – than patients who did not receive the therapy.”


Most Cancer Physicians Would Choose Hospice for Themselves

In a survey of almost 4,500 physicians who treat cancer patients, the majority said that they would enroll in hospice if they themselves had terminal cancer. This was especially true for women, primary care physicians, those with more patients in managed care, and those treating more terminally ill patients. Physicians who expressed a higher preference for hospice for themselves were also more likely to discuss hospice care with their patients early on in treatment, suggesting that personal preferences regarding hospice can influence patient care. The survey’s authors therefore suggest that physicians with negative views of hospice for themselves should consider further educating themselves about how hospice may benefit their patients.