Tuesday, January 29, 2013

What is in the Palliative Care Syringe?

Pay attention! (image only tangentially related to the post, thanks wikimedia)
Remember the landmark trial at MGH by Jennifer Temel that demonstrated palliative care for patients with early stage lung cancer not only improves quality of life, but prolongs survival?  The major question we were left with, as Jennifer says quoting Diane Meier in the accompanying audio interview, is "what is in the palliative care syringe?"  What exactly did they DO to improve quality of life and prolong survival?

Well, now we have some important clues.  In a study published online yesterday in JAMA: Internal Medicine (formerly Archives of Internal Medicine), she mentored a junior researcher named Jaclyn Yoon to examine chart notes from palliative care clinic visits during the MGH trail.  They also examined chart notes from oncologist for those times when the disease progressed.

They found:
  • During the first few patient visits, palliative care clinicians focused on building a relationship, treating symptoms, understanding of prognosis, and establishing preferences for information 
  • When the patients disease progressed, both palliative care clinicians and oncologists addressed plans for end of life care, though oncologists tended to focus more on radiographic progression of disease and medical complications, whereas palliative care docs focused on coping.
This represents an important window into outpatient palliative care encounters.  As I noted in the commentary, these findings are as surprising for what they include as what they do not.  Some might expect that goals of care discussions and hospice would be introduced from the get go - this was not the case.

As the commentary concludes:
The focus of PC is not browbeating patients into accepting hospice and avoiding resuscitation or hospitalization, as some might assume. Palliative care is at its heart a relationship-centered profession. Palliative care clinicians build strong relationships with patients and families in the hopes of finding a way through the symptoms and distress, a way to cope with the illness experience, and a way to make each day as good as it can be. Many patients with serious illness will not have access to an outpatient PC clinician, but they will probably have access to an internist. Patients might benefit if all internists incorporated this approach, seeking supplementary training in PC. And some benefits, like survival, might be surprising.
by: Alex Smith

5 comments:

George Handzo said...

This lesson learned can just as easily guide the practice, not just of physicians, but of all members of the team (nurses, social workers, chaplains,e etc) both in the hospital and in the community.

Kilgore Trout said...

It seems odd that the recent JAMA findings (from the original Temel Lung CA study)suggests that communication and relationship building (components of psychosocial care) is a new medical discovery that needs to be integrated and further studied.

JAMA Study Excerpt: "Further research is needed not only to determine the generalizability of the benefits of early integrated PC but also to identify the components of the intervention that might be most effective," the authors write.

We already know the benefits of early integrated palliative care and what components of interventions are most effective!
Hospice/palliative care social workers and chaplains have been providing this expert care for decades. These palliative professionals are skilled in communication and counseling and comprehensively address profound and complex needs when illness and dying befalls patients and their families. Maybe instead of embarking on a new study to study the old study, first consider the expertise of other palliative team professionals, and the quality outcomes that a team approach produces.

Values in Healthcare said...

Thank you for your post! Glad to see discussion of the importance of relationships in healthcare, especially with patients and families. Many know this, but others don't. Relationships with compassion, respect, etc should be at the center of all care!

Our dream is to restore human values to healthcare around the world. We’re working to enhance relationships, empathy, and healing in healthcare, and created the International Charter for Human Values in Healthcare, starting with the capacity for compassion.

The mission of the International Charter for Human Values in Healthcare is to restore the human dimensions of care – the universal core values that should be present in every healthcare interaction – to healthcare around the world. http://charterforhealthcarevalues.org

Isaac Vielma said...

During my time as a Medical Director of an Inpatient Palliative Care program the physicians were hesitant to refer due to the fear of browbeating patients to choose DNAR/DNI and Hospice Care. As the study showed, we often didn't talk about code status or hospice care. Often times it was about supporting, affirming, relating, listening and being non-judgmental. We would only address those issues at the appropriate time and by the guidance (verbal and non-verbal clues) of the patient. I've long felt that palliative care is very much like a dance. The patient leads and we follow. They dictate the speed, direction and progression of the dance. Our job is to dance along with them through their journey.

Alex Smith said...

Hi Isaac- love the dance analogy. So well put.

Reminds me of what Porter Storey has said, "You do your dance and you walk away." His comment was about relinquishing attachment to needing to "reach" every patient or family member.