Building Relationships through Outpatient Palliative Care

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:04Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:09with the director of
00:09 --> 00:10Yale Cancer Center, doctor Eric
00:10 --> 00:11Winer.
00:11 --> 00:14Yale Cancer Answers features conversations
00:14 --> 00:15with oncologists
00:15 --> 00:16and specialists who are on
00:16 --> 00:17the forefront of the battle
00:17 --> 00:18to fight cancer.
00:19 --> 00:20This week, it's a conversation
00:20 --> 00:22about palliative care with doctor
00:22 --> 00:23Dmitry Kozhevnikov.
00:24 --> 00:24Doctor Kozhevnikov
00:25 --> 00:27is an assistant professor and
00:27 --> 00:29associate program director of the
00:29 --> 00:31Yale hospice palliative medicine fellowship
00:31 --> 00:32at the Yale School of
00:32 --> 00:33Medicine.
00:33 --> 00:34Here's doctor Winer.
00:36 --> 00:38So maybe we can start
00:38 --> 00:40off as I often do,
00:41 --> 00:42hearing a little bit about
00:42 --> 00:44you and and your background.
00:45 --> 00:46So I was actually born
00:46 --> 00:47in the Soviet Union and
00:47 --> 00:48when I was a year
00:48 --> 00:49old, my family escaped
00:50 --> 00:51ethnic conflict that was going
00:51 --> 00:53on in the Caucasus region
00:53 --> 00:54to the US. And we
00:54 --> 00:55settled in New York City
00:55 --> 00:56where I spent most of
00:56 --> 00:57my childhood.
00:58 --> 00:59And my mother was actually,
00:59 --> 01:01and still is, an emergency
01:01 --> 01:02room nurse. And so I
01:02 --> 01:04was exposed to health care
01:05 --> 01:06and medicine at an early age.
01:06 --> 01:07And when I was old
01:07 --> 01:08enough, I actually signed up
01:08 --> 01:09to be a volunteer in
01:09 --> 01:10the ER, and I trained
01:10 --> 01:11myself to be an EMT.
01:12 --> 01:13Can I just ask, was
01:13 --> 01:14she a nurse in the
01:14 --> 01:16Soviet Union and then retrained
01:16 --> 01:17here?
01:17 --> 01:19Now, she went to school here.
01:19 --> 01:20They were very
01:20 --> 01:21young when we came and
01:22 --> 01:23she worked really
01:23 --> 01:25hard to achieve that
01:25 --> 01:26goal and
01:27 --> 01:28was definitely a huge inspiration
01:28 --> 01:29for me, not only to
01:29 --> 01:30go into medicine, but
01:30 --> 01:31overall,]
01:32 --> 01:33as a human being.
01:33 --> 01:34And so
01:35 --> 01:36I ended up being on
01:36 --> 01:37this path to become an
01:37 --> 01:38ER physician,
01:39 --> 01:40but then as I progressed
01:40 --> 01:41through my medical training, I
01:41 --> 01:43realized that it wasn't really
01:44 --> 01:44the setting that I wanted
01:44 --> 01:45to practice in. What
01:45 --> 01:47was more rewarding to me was
01:48 --> 01:49developing these long term relationships
01:49 --> 01:50with patients and
01:52 --> 01:53being able to spend time
01:53 --> 01:54with them and learning about
01:54 --> 01:54them and giving them
01:54 --> 01:56care that was more sort
01:56 --> 01:57of humanistic and
01:58 --> 01:59person centered,
02:00 --> 02:00and I really had the
02:00 --> 02:02time to figure out
02:02 --> 02:03what's important to them and
02:03 --> 02:04how to best care
02:04 --> 02:04for them.
02:05 --> 02:06But I was also influenced
02:06 --> 02:07by a lot of the
02:07 --> 02:08patients that I cared for
02:08 --> 02:09earlier on in my career
02:10 --> 02:11who taught me that medicine
02:11 --> 02:12is a lot more than
02:12 --> 02:14just giving patients the most
02:14 --> 02:16recent and newest treatments.
02:17 --> 02:18It's really about making sure
02:18 --> 02:19that they feel heard and
02:19 --> 02:20listened to
02:21 --> 02:23and understood as well. So
02:23 --> 02:25this power of presence
02:25 --> 02:25is something that I learned
02:25 --> 02:27early on, and I continue
02:27 --> 02:29to do it as
02:29 --> 02:30I practice today.
02:31 --> 02:33And then I learned also
02:33 --> 02:33that
02:34 --> 02:36patients who are facing serious
02:36 --> 02:37illnesses like cancer,
02:37 --> 02:39they want feel as well
02:39 --> 02:40as they can for as
02:40 --> 02:41long as they can. And
02:41 --> 02:42so I knew that doing
02:42 --> 02:44extra training after my internal
02:44 --> 02:44medicine
02:45 --> 02:47residency in hospice and palliative
02:47 --> 02:48medicine was
02:48 --> 02:49one of the best ways
02:49 --> 02:51to gain the skills that
02:51 --> 02:52I needed to help them
02:52 --> 02:53do that.
02:53 --> 02:55And then lastly,
02:56 --> 02:58I followed the love of
02:58 --> 02:59my life. My wife went to
02:59 --> 03:01Connecticut for her training
03:01 --> 03:02in pediatrics when I matched
03:02 --> 03:04to Yale fellowship here.
03:04 --> 03:06And I've been fortunate to
03:06 --> 03:07be here for seven years.
03:07 --> 03:09And like you mentioned, most
03:09 --> 03:10of my time is spent
03:10 --> 03:11seeing patients in our
03:11 --> 03:11clinic.
03:12 --> 03:12But when I'm not doing
03:12 --> 03:14that, I'm either teaching
03:14 --> 03:15other clinicians how to communicate
03:15 --> 03:17effectively with their patients, and
03:18 --> 03:20I'm also training our fellows
03:20 --> 03:21as an associate program director.
03:21 --> 03:22So I've been really fortunate
03:22 --> 03:23with these opportunities.
03:24 --> 03:27Well, I think one cannot
03:29 --> 03:29overstate
03:30 --> 03:31the importance
03:31 --> 03:33of good communication
03:33 --> 03:34between
03:34 --> 03:36clinicians of all sorts,
03:37 --> 03:39doctors, nurses, social workers, what
03:39 --> 03:39have you,
03:40 --> 03:42and patients and their
03:42 --> 03:42families.
03:43 --> 03:45And it's that partnership that's
03:45 --> 03:47really so very critical and
03:48 --> 03:50I think that you really
03:50 --> 03:51help to enhance.
03:53 --> 03:54Let's just
03:55 --> 03:56go right to what people
03:56 --> 03:57always think
03:58 --> 04:00and dispel some myths.
04:01 --> 04:03So people hear words like
04:03 --> 04:04hospice,
04:05 --> 04:06and they think
04:06 --> 04:07things like
04:08 --> 04:09my doctor's given up on
04:09 --> 04:11me. I'm just going someplace
04:11 --> 04:13or I'm going on some
04:13 --> 04:13program,
04:14 --> 04:15that's at the very end
04:15 --> 04:16of my life.
04:18 --> 04:19And while there are
04:20 --> 04:21certain situations where that seems
04:21 --> 04:23to be the case, it's
04:23 --> 04:25really not using palliative care
04:25 --> 04:27and hospice to its best
04:27 --> 04:29advantage at all.
04:30 --> 04:31Help to educate
04:32 --> 04:33our listeners.
04:33 --> 04:34Of course.
04:34 --> 04:36So in taking a step
04:36 --> 04:37back, we know that there
04:37 --> 04:38are about thirteen million adults
04:38 --> 04:39in the US with a
04:39 --> 04:40serious illness.
04:42 --> 04:43And patients with a serious
04:43 --> 04:44illness often have needs that
04:44 --> 04:46are unique
04:46 --> 04:47and require a tailored approach
04:48 --> 04:49and extra support in different
04:49 --> 04:51areas, not only the
04:51 --> 04:53physical experience, but their psychosocial
04:54 --> 04:56experience, spiritual, and there's other
04:56 --> 04:57areas that we focus on.
04:58 --> 04:59But palliative medicine, the way
04:59 --> 05:00I think about it, is
05:00 --> 05:01subspecialized
05:01 --> 05:02medical care for patients with
05:02 --> 05:04a serious illness that is
05:04 --> 05:06provided by high functioning teams,
05:07 --> 05:08ones that are composed of
05:08 --> 05:08physicians,
05:09 --> 05:10nurses, nurse practitioners,
05:11 --> 05:13chaplains, social workers,
05:13 --> 05:15psychologists, pharmacists. So,
05:16 --> 05:18multiple people of different training
05:18 --> 05:19and backgrounds
05:19 --> 05:21that all come together and
05:21 --> 05:22try to figure out where
05:22 --> 05:24extra support can be
05:24 --> 05:25added to the patients. And
05:26 --> 05:27the beautiful thing about palliative
05:27 --> 05:28care is that it can
05:28 --> 05:29be provided to patients at
05:29 --> 05:30any age and any stage
05:30 --> 05:32of an illness from diagnosis
05:32 --> 05:33to later on.
05:33 --> 05:35And people do not lose
05:35 --> 05:36anything by
05:36 --> 05:38receiving palliative care because it's
05:38 --> 05:39just an extra layer of
05:39 --> 05:41support on top of what
05:41 --> 05:42their on. For example, their
05:42 --> 05:44oncologist is doing for them.
05:44 --> 05:45So hospice is a type
05:45 --> 05:47of palliative care that's only
05:47 --> 05:49provided, like you mentioned, to
05:49 --> 05:49patients
05:50 --> 05:50who are thought to be
05:50 --> 05:52in sort of the last
05:52 --> 05:53six months of their lives
05:53 --> 05:54but not
05:54 --> 05:56necessarily the last week of
05:56 --> 05:58their lives either. Absolutely. Yeah.
05:58 --> 05:59And, you know,
05:59 --> 06:00what we've found is that
06:00 --> 06:01patients who
06:02 --> 06:04enroll in hospice sooner get
06:04 --> 06:05more time to benefit from
06:05 --> 06:06the support and the services
06:06 --> 06:08and actually have better quality
06:08 --> 06:09of life. So we try
06:09 --> 06:10to encourage that whenever
06:10 --> 06:12we're seeing a situation
06:12 --> 06:14where a patient may not
06:14 --> 06:16want further treatment because it
06:16 --> 06:17doesn't fit their goals or
06:17 --> 06:19they aren't unfortunately a candidate
06:19 --> 06:21for any more treatment, we
06:21 --> 06:22try to get them as
06:22 --> 06:23much support as we can
06:23 --> 06:24at that moment. And hospice
06:24 --> 06:25is one way to do
06:25 --> 06:25that.
06:26 --> 06:28And palliative care, as you've
06:28 --> 06:30mentioned, goes way beyond hospice,
06:30 --> 06:31and palliative care is
06:31 --> 06:33really focused on
06:33 --> 06:34maximizing
06:34 --> 06:36patient comfort, not just physical
06:36 --> 06:38comfort as you've already pointed
06:38 --> 06:40out along the way.
06:41 --> 06:43And, you know, I've often
06:43 --> 06:44been struck
06:44 --> 06:46by the fact that
06:46 --> 06:48if someone's resistant
06:48 --> 06:49to palliative care,
06:49 --> 06:51that on some level, they're
06:51 --> 06:53indicating that they are
06:53 --> 06:55comfortable not being comfortable.
06:55 --> 06:57And of course, many
06:57 --> 06:58oncologists
06:58 --> 07:00are fairly skilled at providing
07:01 --> 07:03appropriate palliative care, but
07:03 --> 07:05having a dedicated
07:05 --> 07:07team member like you can
07:07 --> 07:08often be very helpful.
07:09 --> 07:10Yeah. We are
07:10 --> 07:11so appreciative of when we're
07:11 --> 07:13involved. And I think, one
07:13 --> 07:14of the examples that comes
07:14 --> 07:15to mind when I
07:16 --> 07:18try to help people figure
07:19 --> 07:20out the difference and realize
07:20 --> 07:21the difference between the two
07:21 --> 07:23fields, hospice and palliative care,
07:24 --> 07:25is, by sharing a
07:25 --> 07:26brief patient story without any
07:26 --> 07:28details, but just to
07:28 --> 07:29give people an idea of what
07:29 --> 07:31it might look like. So
07:31 --> 07:32one of my patients
07:33 --> 07:34has metastatic breast cancer, and
07:34 --> 07:35she's been seeing us
07:35 --> 07:37for five years already. So
07:37 --> 07:38we've been very involved in
07:38 --> 07:38her care
07:39 --> 07:40from diagnosis.
07:40 --> 07:42And she's actually a patient
07:42 --> 07:42of Doctor Sanft who I
07:42 --> 07:43know you've had on the
07:43 --> 07:45program recently, who's a very
07:45 --> 07:46respected colleague of mine. And
07:46 --> 07:47it's really nice to
07:47 --> 07:48be able to collaborate with
07:48 --> 07:50her. And one of the
07:50 --> 07:51things we helped this
07:51 --> 07:53patient, and other
07:53 --> 07:54patients is with cancer related
07:54 --> 07:57pain, nausea, other symptoms while
07:57 --> 07:59she's going through different treatments
07:59 --> 07:59that
08:00 --> 08:01might change at different
08:01 --> 08:02points in time. And so
08:03 --> 08:04we see her every three
08:04 --> 08:06months. We check-in on how
08:06 --> 08:07she's doing physically,
08:08 --> 08:10emotionally, and we celebrate the
08:10 --> 08:11good things with her. So,
08:11 --> 08:12for example, she went on
08:12 --> 08:14a cruise recently. I was
08:14 --> 08:15really excited that she was
08:15 --> 08:16able to do that because
08:16 --> 08:17she was feeling well enough
08:18 --> 08:19to travel and spend
08:19 --> 08:20that time. And it was
08:20 --> 08:21really rewarding to know
08:21 --> 08:22that we played
08:22 --> 08:23a role in sort
08:23 --> 08:25of making that happen. You
08:25 --> 08:26know, and in much the
08:26 --> 08:28same way that cancer treatment,
08:28 --> 08:30the drugs we use to
08:30 --> 08:31to treat cancers,
08:31 --> 08:33have become ever so much
08:33 --> 08:35more complicated over time.
08:35 --> 08:38Approaches to pain control, approaches
08:39 --> 08:40to the management of other
08:40 --> 08:40symptoms
08:41 --> 08:43have also become more complicated,
08:43 --> 08:45and it's pretty hard
08:45 --> 08:46for any one individual to
08:46 --> 08:47keep all of this in
08:47 --> 08:48their head.
08:50 --> 08:52I'll just use another
08:52 --> 08:54example. You know, patients will
08:54 --> 08:56occasionally ask for a medicine
08:56 --> 08:58for depression or for some
08:58 --> 08:58other
08:59 --> 09:00emotional, psychological problem.
09:01 --> 09:03And my response is usually,
09:03 --> 09:04you know, I can give
09:04 --> 09:05you something, but I'm not
09:05 --> 09:06the expert in this area.
09:07 --> 09:09I have expertise as
09:09 --> 09:10well, but I draw
09:10 --> 09:12more on my team members,
09:12 --> 09:14like my social worker. We
09:14 --> 09:14have a psychologist.
09:15 --> 09:16So I think the beauty
09:16 --> 09:17of our field is that
09:17 --> 09:19we accept the fact that
09:19 --> 09:20we know
09:20 --> 09:21a certain degree
09:22 --> 09:23of things about
09:24 --> 09:26depression or pain or anxiety
09:27 --> 09:28or nausea, but we draw
09:28 --> 09:29on each other to really
09:29 --> 09:31fill in the gaps. And
09:31 --> 09:32I think talk therapy is
09:32 --> 09:33really something that helps a
09:33 --> 09:34lot of folks and
09:35 --> 09:36support groups is another area
09:36 --> 09:38where some of our patients
09:38 --> 09:38come back to us and
09:38 --> 09:39say, you know, it's amazing
09:39 --> 09:41to really be in a
09:41 --> 09:42group of people who understand
09:42 --> 09:43and know what I'm going
09:43 --> 09:45through. Even though there are
09:45 --> 09:46plenty of people around me
09:46 --> 09:47that kind of are
09:47 --> 09:48aware of it, it's
09:48 --> 09:49a totally different thing to be
09:51 --> 09:52really talking about it with
09:52 --> 09:52folks
09:53 --> 09:54kind of in a similar
09:54 --> 09:54situation.
09:55 --> 09:56Now, of course, when we
09:56 --> 09:58get other doctors involved in
09:58 --> 09:59caring for our patients,
09:59 --> 10:00one of the
10:02 --> 10:03key issues is sometimes
10:04 --> 10:04communication
10:05 --> 10:06among us. How do you
10:06 --> 10:07approach that, and how do
10:07 --> 10:09you think about that? Because,
10:09 --> 10:11of course, there's always
10:11 --> 10:12the potential when you have
10:13 --> 10:14two and three and four
10:14 --> 10:15doctors taking care of one
10:15 --> 10:15patient
10:16 --> 10:17that there are mixed messages
10:19 --> 10:20and some miscommunication.
10:21 --> 10:23That's such an important point.
10:23 --> 10:23And
10:24 --> 10:25what we know is that
10:25 --> 10:28when we communicate better and
10:28 --> 10:28more
10:29 --> 10:29smoothly,
10:30 --> 10:31without the patient there, I
10:31 --> 10:32think when we talk to
10:32 --> 10:33patients, we actually
10:34 --> 10:35have a more uniform
10:36 --> 10:38message that
10:38 --> 10:40is the same from different
10:40 --> 10:41people, which is so important
10:41 --> 10:42because one of the things
10:42 --> 10:44I hear that's so frustrating, and
10:45 --> 10:46I can imagine this as
10:46 --> 10:47well, is hearing one thing
10:47 --> 10:49from one doctor and then
10:49 --> 10:50another thing from another nurse.
10:50 --> 10:52And so we really emphasize
10:52 --> 10:54working together closely
10:54 --> 10:55and supporting each other because
10:55 --> 10:56a lot of these
10:57 --> 10:58experiences we have in medicine
10:58 --> 11:01as clinicians can be really
11:01 --> 11:01challenging and
11:02 --> 11:03sort of lead us to
11:03 --> 11:05feel like how can
11:05 --> 11:06we provide empathy when we're
11:06 --> 11:08going through such a difficult
11:08 --> 11:10times ourselves. But I think
11:10 --> 11:11as we support each other,
11:11 --> 11:13that's another benefit of
11:13 --> 11:14having such an interdisciplinary
11:14 --> 11:16team. We can provide better
11:16 --> 11:17care and more
11:18 --> 11:20consistent message and communication to
11:20 --> 11:21the patients too.
11:21 --> 11:22You know, I haven't done
11:22 --> 11:23this
11:23 --> 11:24to the best of
11:24 --> 11:26my recollection with working with
11:26 --> 11:27a palliative care doctor. But
11:27 --> 11:29oftentimes, when patients are referred
11:29 --> 11:31in by other oncologists
11:31 --> 11:32in the presence of the
11:32 --> 11:33patient,
11:33 --> 11:35I will use my
11:36 --> 11:36cell phone
11:37 --> 11:39and call the oncologist and
11:39 --> 11:40put that person on speaker
11:40 --> 11:42phone so that we're all
11:42 --> 11:43communicating together.
11:43 --> 11:44And I found that to
11:44 --> 11:46be very useful in much
11:46 --> 11:47the same way that I
11:47 --> 11:49would imagine that for you,
11:49 --> 11:51communicating together is often
11:52 --> 11:54really a way
11:54 --> 11:55of avoiding a lot of
11:55 --> 11:56challenges.
11:56 --> 11:57I love that idea, Eric.
11:57 --> 11:59And, you know, that's something
11:59 --> 12:00I could probably do more
12:00 --> 12:01often, but what worked
12:01 --> 12:02for a lot of my
12:02 --> 12:03colleagues and myself is
12:03 --> 12:04also
12:04 --> 12:05even if it's just messaging
12:06 --> 12:07before and after appointments because
12:07 --> 12:09everyone's so busy. But when
12:09 --> 12:10I have that opportunity, I
12:10 --> 12:12always jump on it, because
12:13 --> 12:14patients wanna know that the
12:14 --> 12:16people that they trust, their
12:16 --> 12:17oncologist, their primary care doctor
12:17 --> 12:18in many circumstances
12:19 --> 12:20are involved and agree
12:20 --> 12:22with what's going on. So
12:22 --> 12:23we definitely try to incorporate
12:23 --> 12:23everyone.
12:24 --> 12:25Well, we're gonna have to
12:25 --> 12:26take a break in about
12:26 --> 12:28a minute. But let me
12:28 --> 12:30just ask you one question
12:30 --> 12:31before the break, which is,
12:32 --> 12:34how old is palliative care
12:34 --> 12:35in the world of
12:35 --> 12:36cancer?
12:36 --> 12:38When did this all start,
12:38 --> 12:39and when do you
12:39 --> 12:40feel that it really
12:41 --> 12:42picked up in terms of
12:42 --> 12:44getting traction among the
12:44 --> 12:46oncology community?
12:46 --> 12:47That's a good one to
12:47 --> 12:49answer in forty five seconds,
12:49 --> 12:50but I
12:50 --> 12:51think I can do it.
12:51 --> 12:53So, palliative care as an
12:53 --> 12:54idea has been around since
12:54 --> 12:56the sixties, nineteen fifties and
12:56 --> 12:57sixties when
12:58 --> 12:59folks around the world,
12:59 --> 13:00but I think primarily in
13:00 --> 13:02the UK, recognized that patients
13:02 --> 13:03who were dying of cancer
13:04 --> 13:05had very poorly controlled symptoms
13:05 --> 13:07and very little support.
13:08 --> 13:08And so there was this
13:08 --> 13:09movement
13:10 --> 13:12abroad to build that support,
13:12 --> 13:13and it turned into the
13:13 --> 13:15hospice movement in
13:15 --> 13:17the nineteen seventies and eighties
13:17 --> 13:19with Connecticut hospice in Branford
13:19 --> 13:19being the first one in
13:19 --> 13:20the United States.
13:22 --> 13:22And,
13:23 --> 13:24what happened then was this
13:26 --> 13:27growth from hospice,
13:28 --> 13:29of the palliative care movement
13:29 --> 13:31recognizing that, you know, patients
13:31 --> 13:32way earlier than the end
13:32 --> 13:33of their lives need the
13:33 --> 13:34support as well while they're
13:34 --> 13:36going through the treatment, and
13:36 --> 13:37that could be for many
13:37 --> 13:38years.
13:38 --> 13:39So that was
13:39 --> 13:40a huge gap that I
13:40 --> 13:41think grew in the early
13:41 --> 13:42two thousands and with
13:43 --> 13:45our specialty being recognized actually
13:45 --> 13:46in two thousand eight. So
13:46 --> 13:47it hasn't been too long
13:47 --> 13:49with that official recognition,
13:49 --> 13:50but the ideas have been
13:50 --> 13:51around for a while.
13:51 --> 13:53An old problem, but a field,
13:54 --> 13:56maybe not in its infancy,
13:56 --> 13:57but certainly not beyond adolescence.
13:58 --> 13:59Alright.
13:59 --> 14:01We will take a brief
14:01 --> 14:02break, and we'll be back
14:02 --> 14:03with you in just a
14:03 --> 14:04minute.
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14:21 --> 14:24The American Cancer Society estimates
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14:28 --> 14:29this
14:29 --> 14:31year, making up about four
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14:39 --> 14:41Clinical trials are currently underway
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14:44 --> 14:46centers such as Yale Cancer
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14:48 --> 14:50to test innovative new treatments
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14:52 --> 14:54Yale Cancer Center was recently
14:54 --> 14:56awarded grants from the National
14:56 --> 14:58Institutes of Health to fund
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15:02 --> 15:02Excellence,
15:03 --> 15:03or SPORE,
15:04 --> 15:06to address critical barriers to
15:06 --> 15:07treatment of head and neck
15:07 --> 15:09squamous cell carcinoma due to
15:09 --> 15:11resistance to immune DNA damaging
15:11 --> 15:13and targeted therapy.
15:13 --> 15:15More information is available at
15:15 --> 15:17yale cancer center dot org.
15:17 --> 15:19You're listening to Connecticut Public
15:19 --> 15:19Radio.
15:21 --> 15:22This is Eric Winer with
15:22 --> 15:23Yale Cancer Answers.
15:24 --> 15:26I'm joined tonight by our
15:26 --> 15:28guest, doctor Dmitry
15:29 --> 15:29Kozhevnikov,
15:30 --> 15:32who is an assistant professor
15:33 --> 15:35at Yale School of Medicine,
15:36 --> 15:37in the Department of Medicine,
15:38 --> 15:40and is a palliative care
15:40 --> 15:41expert directing
15:42 --> 15:42our
15:43 --> 15:44ambulatory palliative care program.
15:49 --> 15:50Let's get back to the discussion
15:50 --> 15:51about
15:52 --> 15:54palliative care and when palliative
15:55 --> 15:55care started.
15:57 --> 15:59When do you think that,
16:00 --> 16:01and I realize there's no
16:01 --> 16:03single answer to this, but
16:03 --> 16:04when do you think it's
16:04 --> 16:06the right time to introduce
16:06 --> 16:07the concept
16:07 --> 16:09of palliative care
16:09 --> 16:11to a patient with cancer?
16:13 --> 16:14You know, it's probably not
16:14 --> 16:16something you're gonna introduce to
16:16 --> 16:18a woman with
16:19 --> 16:21very early stage breast cancer
16:21 --> 16:22who's having a lumpectomy and
16:22 --> 16:24radiation and going on a
16:25 --> 16:26pill to prevent a recurrence.
16:26 --> 16:27But
16:27 --> 16:28what are the situations where
16:28 --> 16:30you think about this?
16:30 --> 16:31I think about this a
16:31 --> 16:31lot. And, you know, one
16:31 --> 16:32of the challenges that we
16:32 --> 16:33face is that
16:34 --> 16:35there is a shortage of
16:35 --> 16:36palliative care experts in the
16:36 --> 16:37country. For example,
16:37 --> 16:39for every hundred thousand patients or
16:41 --> 16:42folks
16:42 --> 16:43in the country, there are
16:43 --> 16:45eight cardiologists and five oncologists,
16:45 --> 16:47but only two palliative care
16:47 --> 16:48physicians. So this kind of
16:48 --> 16:50illustrates the challenges that we
16:50 --> 16:52are juggling when we're thinking
16:52 --> 16:53about who to
16:53 --> 16:54get involved with and how
16:54 --> 16:54early.
16:55 --> 16:57Technically, we can get involved
16:57 --> 16:59in patients care at diagnosis.
17:00 --> 17:00But what I've
17:01 --> 17:03found in working with oncologists
17:03 --> 17:04and some of the research
17:04 --> 17:05that's happened over the past
17:05 --> 17:07few years, kind of is
17:07 --> 17:08trying to find that sweet
17:08 --> 17:09spot of, you know, it
17:09 --> 17:10seems to be more when
17:10 --> 17:12patients have some sort of
17:12 --> 17:13unmet need.
17:13 --> 17:14And and that could be,
17:14 --> 17:17again, physical with cancer related
17:17 --> 17:18pain. That could be symptoms
17:19 --> 17:20that are related to their
17:20 --> 17:21treatments. And
17:22 --> 17:23those are the patients that
17:23 --> 17:25I think benefit the most
17:25 --> 17:26and come back to us.
17:26 --> 17:27It can't hurt to explain
17:27 --> 17:28what palliative care is to
17:28 --> 17:30any patient with cancer, but
17:30 --> 17:31but getting them to come
17:31 --> 17:33to another appointment can often
17:33 --> 17:35be challenging with so many
17:35 --> 17:36other appointments. So it's sort
17:36 --> 17:37of weighing the benefits
17:37 --> 17:38and the burdens of
17:38 --> 17:39that as well.
17:40 --> 17:41And do you feel like,
17:41 --> 17:43you know, in these last
17:43 --> 17:44twenty years
17:45 --> 17:46that the field has has
17:46 --> 17:48changed a great deal?
17:48 --> 17:50I do. Yeah. I think
17:50 --> 17:51twenty years ago, the focus
17:51 --> 17:53was more on
17:53 --> 17:55building inpatient palliative care teams.
17:55 --> 17:57So teams that are
17:57 --> 17:58seeing patients while they're in
17:58 --> 17:58the hospital,
17:59 --> 18:00admitted with some sort of
18:00 --> 18:01acute issue.
18:01 --> 18:03And that has really
18:03 --> 18:05been a huge area of
18:05 --> 18:06growth to the point where
18:06 --> 18:07now, you know, ninety percent
18:07 --> 18:08of all hospitals in the
18:08 --> 18:10country have at least some
18:10 --> 18:11sort of palliative care team.
18:11 --> 18:12And what's happening now is
18:12 --> 18:14the realization that while we don't
18:15 --> 18:17provide these services sooner before
18:17 --> 18:18patients get sick
18:19 --> 18:20while they're stable and going
18:20 --> 18:22through treatment in the outpatient
18:22 --> 18:24setting. And so the
18:24 --> 18:26growth of ambulatory, or
18:26 --> 18:28outpatient palliative care
18:28 --> 18:30teams has picked up
18:30 --> 18:31over the last few years as
18:32 --> 18:33patients and families and
18:34 --> 18:35clinicians and hospital systems
18:35 --> 18:37realize the benefits
18:37 --> 18:39of involving us sooner.
18:40 --> 18:41And
18:41 --> 18:42is inpatient
18:43 --> 18:44palliative care
18:44 --> 18:45or,
18:46 --> 18:48institutions like Connecticut Hospice that,
18:48 --> 18:49you know, initially
18:50 --> 18:50had
18:52 --> 18:54dozens and dozens of patients
18:54 --> 18:56there who were
18:56 --> 18:57living the end of their
18:57 --> 18:58life in a facility,
18:59 --> 19:00has that remained the same
19:00 --> 19:02way, or is there more
19:02 --> 19:02of a push to get
19:02 --> 19:03people home?
19:05 --> 19:06I think that most people
19:06 --> 19:07wanna be at home. There
19:07 --> 19:09are certainly cases that are
19:09 --> 19:10really challenging to treat at
19:10 --> 19:12home, whether that's because of
19:12 --> 19:14symptoms or limited support.
19:14 --> 19:16But about ninety five or
19:16 --> 19:17ninety six percent of patients
19:17 --> 19:19on hospice in the country
19:19 --> 19:20are at home
19:20 --> 19:21or outside of the hospital.
19:23 --> 19:24And there is a push
19:24 --> 19:25really, I would say, to
19:25 --> 19:27align the treatment that we're
19:27 --> 19:27giving
19:28 --> 19:28to patients
19:29 --> 19:31and the families with what
19:31 --> 19:32their goals are within limits,
19:32 --> 19:33obviously. And there
19:33 --> 19:35are cases that we're involved
19:35 --> 19:36with that are very complex.
19:36 --> 19:38And maybe the patient wants
19:38 --> 19:38to be at home, but
19:38 --> 19:39they're not able to
19:39 --> 19:41for various reasons. So
19:41 --> 19:42we try to find a
19:42 --> 19:42middle ground and work with
19:42 --> 19:43them.
19:43 --> 19:45But it
19:45 --> 19:47used to be that inpatient
19:47 --> 19:49hospice units were accepting
19:49 --> 19:51patients who might not be
19:52 --> 19:53towards the end of their
19:53 --> 19:54lives or not have
19:54 --> 19:56symptoms that could be managed
19:56 --> 19:57somewhere else. But now with
19:57 --> 19:59Medicare regulations being what they
19:59 --> 20:00are, there's really
20:01 --> 20:02a emphasis on
20:02 --> 20:04making sure that patients who
20:04 --> 20:05are in the inpatient
20:05 --> 20:07hospice unit or hospital
20:07 --> 20:09with hospice services
20:09 --> 20:11require that level of care,
20:11 --> 20:12just because that is
20:12 --> 20:14sort of our system. And
20:14 --> 20:15I wish it wasn't,
20:15 --> 20:16but that's sort of where
20:16 --> 20:17we are.
20:17 --> 20:18And I think the point that
20:18 --> 20:20I wanna leave listeners with
20:20 --> 20:22is that the goal of
20:22 --> 20:23palliative care teams is really
20:23 --> 20:24to make sure that
20:24 --> 20:26patients are being heard
20:26 --> 20:27and aligning
20:27 --> 20:29their values and and hopes
20:29 --> 20:30with whatever the other doctors
20:30 --> 20:32that we work with are
20:32 --> 20:33offering and doing for the
20:33 --> 20:34patient.
20:35 --> 20:37Yeah. No. I think that's
20:38 --> 20:39really, really,
20:40 --> 20:41very critical.
20:45 --> 20:45So
20:47 --> 20:48what are the kinds of
20:48 --> 20:50services that you're able to
20:50 --> 20:52offer in the outpatient setting?
20:53 --> 20:54Sure. Our team is
20:55 --> 20:56fantastic. I can't speak enough
20:56 --> 20:57about them. But usually, when
20:57 --> 20:58patients come to us, they
20:58 --> 20:59have a medical visit first
20:59 --> 21:01with either a physician or
21:01 --> 21:01an APRN.
21:02 --> 21:04And at that point
21:04 --> 21:05is when we
21:05 --> 21:07evaluate whether or not there
21:07 --> 21:08are unmet symptoms or
21:08 --> 21:09needs.
21:09 --> 21:10And those could be things
21:10 --> 21:12like I mentioned earlier, physical
21:12 --> 21:14or psychosocial, sometimes they're financial,
21:15 --> 21:16sometimes they're spiritual.
21:16 --> 21:16So,
21:17 --> 21:19we work very closely with
21:19 --> 21:20our social workers to see
21:20 --> 21:22whether there are either resources
21:22 --> 21:24that aren't being tapped into
21:24 --> 21:25grants or other,
21:26 --> 21:28financial, you know, things that
21:28 --> 21:29that can be looked at.
21:29 --> 21:30But also,
21:31 --> 21:32how people are coping.
21:32 --> 21:33How are they doing with
21:33 --> 21:35this new diagnosis? Because everybody's
21:35 --> 21:37different, but this is
21:37 --> 21:37a heavy thing to deal
21:37 --> 21:39with. So we look at
21:39 --> 21:40it from different perspectives. And
21:40 --> 21:42if someone does say, hey,
21:42 --> 21:43I would really benefit from
21:44 --> 21:45talking to someone about this.
21:45 --> 21:46We can offer them visits
21:46 --> 21:48with our psychologist or
21:48 --> 21:49even our social worker checking
21:49 --> 21:50with them periodically.
21:50 --> 21:52And we tailor it to
21:52 --> 21:53whatever their needs are. There
21:53 --> 21:53there are some patients that
21:53 --> 21:55meet who
21:55 --> 21:57really are doing well, and
21:57 --> 21:58we check-in maybe every six
21:58 --> 21:59months or a year. And
21:59 --> 22:01then if things change, we
22:01 --> 22:02can change the frequency of
22:02 --> 22:03visits.
22:03 --> 22:04So it's really a personalized
22:05 --> 22:05experience.
22:06 --> 22:08It is dramatic how different
22:08 --> 22:10people cope so differently,
22:11 --> 22:13and react so differently to
22:13 --> 22:13a diagnosis
22:14 --> 22:15of cancer or really any
22:15 --> 22:16other diagnosis. And I think
22:16 --> 22:18the trap you can fall
22:18 --> 22:18into
22:18 --> 22:20as a clinician
22:20 --> 22:21is to expect people to
22:21 --> 22:23behave a certain way,
22:23 --> 22:24and you really have to
22:24 --> 22:25be open to all the
22:25 --> 22:26surprises.
22:26 --> 22:28So let's talk about
22:29 --> 22:31some people who often don't
22:31 --> 22:32get talked about,
22:32 --> 22:34and that is the family
22:34 --> 22:34members.
22:35 --> 22:37Because as we talk more
22:37 --> 22:39about hospice at home,
22:40 --> 22:42this often puts
22:42 --> 22:45a pretty significant burden on
22:45 --> 22:47the family members
22:47 --> 22:49in the home and sometimes
22:49 --> 22:50outside of the home, and
22:50 --> 22:51it's not always family. Sometimes
22:51 --> 22:52it's friends.
22:55 --> 22:55Yeah.
22:58 --> 22:59I can only imagine what
22:59 --> 23:00it's like to have
23:01 --> 23:01this
23:02 --> 23:03role of being a
23:03 --> 23:05caregiver for a family member
23:06 --> 23:06at this time of their
23:06 --> 23:07lives.
23:08 --> 23:09It's obviously an honor and
23:09 --> 23:10a privilege for most
23:10 --> 23:11people, but it's such
23:11 --> 23:12a hard thing to do
23:12 --> 23:14with everything that's
23:14 --> 23:15going on in their own
23:15 --> 23:16lives. So,
23:17 --> 23:18as much as we can't
23:18 --> 23:19fix everything, what we can
23:19 --> 23:21do is look at each
23:21 --> 23:23situation and try to guide
23:23 --> 23:24folks on what makes sense
23:24 --> 23:26for them, whether that is
23:27 --> 23:29getting family members mobilized and
23:30 --> 23:31sort of taking shifts and
23:31 --> 23:32turns,
23:32 --> 23:33taking care of their loved
23:33 --> 23:36one, or it's private paying
23:36 --> 23:37for an aide a few
23:37 --> 23:38hours a week
23:40 --> 23:41or looking at the
23:41 --> 23:42situation kind of from a
23:42 --> 23:43bird's eye view.
23:43 --> 23:44And because sometimes
23:45 --> 23:46we're so narrow focused, even
23:46 --> 23:48myself, that we kind of
23:48 --> 23:49forget that's a
23:49 --> 23:50really important thing to look
23:50 --> 23:52at. And supporting our caregivers
23:52 --> 23:53is one of our priorities
23:53 --> 23:54as a team as well
23:54 --> 23:56because we know that
23:56 --> 23:58without the
23:58 --> 23:59caregiver being so involved, the
23:59 --> 24:01patients are not as well
24:01 --> 24:02taken care of. So,
24:02 --> 24:04I think that, you know,
24:04 --> 24:05every day when we see
24:05 --> 24:06patients, we're always looking out
24:06 --> 24:07for how are the caregivers
24:09 --> 24:10how are you doing?
24:10 --> 24:11I know you're
24:11 --> 24:12taking such good care of
24:12 --> 24:13your mother,
24:14 --> 24:15but let's take a minute
24:15 --> 24:16and breathe. And are
24:16 --> 24:17you eating? Are you sleeping?
24:18 --> 24:19What's going on in your
24:19 --> 24:20life too? And this can
24:20 --> 24:22often go on for an
24:22 --> 24:23extended period of time. I
24:23 --> 24:24mean, there are
24:25 --> 24:25people who
24:26 --> 24:28live very active lives until
24:28 --> 24:29very close to
24:30 --> 24:31the very end.
24:32 --> 24:34But there are others, particularly
24:34 --> 24:34people who
24:35 --> 24:36may be older or may
24:36 --> 24:38have more in the way
24:38 --> 24:40of other illnesses who just,
24:41 --> 24:41are really
24:42 --> 24:42incapacitated
24:43 --> 24:44for a longer period of
24:44 --> 24:45time. And it is
24:45 --> 24:47a huge burden for
24:47 --> 24:49the family members.
24:49 --> 24:50And, you know, the other
24:50 --> 24:51issue, of course, is that
24:51 --> 24:53some family members are just
24:53 --> 24:55more medically savvy than others.
24:57 --> 24:58That's right. So there is
24:58 --> 25:00a big piece of education.
25:00 --> 25:01Do you,
25:02 --> 25:03see a role for support
25:03 --> 25:05groups for family members?
25:05 --> 25:06Definitely. Yeah.
25:08 --> 25:09I know that our system
25:09 --> 25:11and Smilow in particular
25:11 --> 25:13does have caregiver support groups
25:13 --> 25:13available.
25:14 --> 25:15So I would ask about
25:15 --> 25:17that for any caregivers.
25:18 --> 25:19And there are also plenty
25:19 --> 25:20of online resources that I've
25:20 --> 25:21kind of been surprised to
25:21 --> 25:22learn about. I mean, you
25:22 --> 25:23wouldn't think about
25:23 --> 25:25it, but Facebook is a
25:25 --> 25:26good place to find
25:27 --> 25:28patients with multiple
25:28 --> 25:30myeloma or breast cancer or
25:30 --> 25:32caregivers of patients with those
25:32 --> 25:32diseases.
25:33 --> 25:34And there are other
25:34 --> 25:35websites that I can't think
25:35 --> 25:36of off the top of
25:36 --> 25:36my head, but there
25:36 --> 25:38are certainly other resources that
25:38 --> 25:40we try to help patients
25:40 --> 25:40find, and they often find them
25:42 --> 25:43on their own as well.
25:45 --> 25:47I'm struck again about
25:47 --> 25:48communication.
25:51 --> 25:53When we talk about patients
25:53 --> 25:54and families,
25:54 --> 25:55sometimes,
25:56 --> 25:57there isn't
25:57 --> 25:59perfect communication
25:59 --> 26:00between the two.
26:01 --> 26:03And that's often about the
26:03 --> 26:04family member protecting the patient
26:04 --> 26:06and the patient protecting the
26:06 --> 26:07family member.
26:07 --> 26:09Just wondering your thoughts
26:09 --> 26:10on that and
26:10 --> 26:12how you and your team
26:14 --> 26:15deal with that challenge.
26:16 --> 26:17Yeah. I think we
26:18 --> 26:18recognize
26:19 --> 26:21that patients and their caregivers
26:21 --> 26:22and their loved ones and
26:22 --> 26:24their social structure around them,
26:25 --> 26:27are often very well established.
26:27 --> 26:28And we don't
26:28 --> 26:29try to change
26:29 --> 26:30that to a degree, you
26:30 --> 26:32know, unless it's unsafe
26:32 --> 26:33for any reason. But, you
26:33 --> 26:35know, most families have some
26:35 --> 26:36sort of tension points or
26:36 --> 26:39disagreements and challenges. So our
26:39 --> 26:40role is really not to
26:40 --> 26:41to be the fixers there,
26:41 --> 26:42but to
26:43 --> 26:43help
26:44 --> 26:46within that context to try
26:46 --> 26:47to help them as they
26:47 --> 26:49face this serious illness,
26:49 --> 26:52and sometimes be the sort
26:52 --> 26:52of the mediator
26:53 --> 26:53between
26:55 --> 26:56conflicts.
26:59 --> 26:59And
27:00 --> 27:01that's an area where
27:03 --> 27:04I think it can be
27:04 --> 27:05very meaningful because there might
27:05 --> 27:06be a barrier
27:07 --> 27:08there that's a conflict that's preventing
27:08 --> 27:09a patient from getting the
27:09 --> 27:11right treatment or from
27:11 --> 27:12getting the right care at
27:12 --> 27:14home and trying to listen
27:14 --> 27:16to both sides and figure
27:16 --> 27:17out a solution is really
27:17 --> 27:17important.
27:18 --> 27:19Well, I think that one
27:19 --> 27:20of the things we see,
27:20 --> 27:22and I'm gonna now paraphrase
27:24 --> 27:26from Tolstoy's Anna Karenina,
27:27 --> 27:28that
27:28 --> 27:30all happy families are alike
27:30 --> 27:32and all unhappy families are
27:32 --> 27:34unhappy in their unique way.
27:34 --> 27:36I think that families that
27:36 --> 27:38function really well together
27:40 --> 27:41do better
27:41 --> 27:44in these hospice situations. And
27:44 --> 27:45those where there's a lot
27:45 --> 27:45of
27:46 --> 27:46conflict
27:47 --> 27:47have trouble.
27:48 --> 27:50Of course. Yeah. I really
27:50 --> 27:51appreciate your Tolstoy
27:51 --> 27:52reference.
27:53 --> 27:54It seemed appropriate.
27:54 --> 27:56Definitely. And, you know,
27:56 --> 27:57one of the hardest things
27:57 --> 27:57that we see, and you
27:57 --> 27:58probably see this a lot
27:58 --> 28:00too, is where patients
28:00 --> 28:02maybe they're estranged from
28:02 --> 28:03family and they don't really
28:03 --> 28:04have much support. And,
28:05 --> 28:07our system is just designed
28:07 --> 28:08in a way that's really
28:08 --> 28:09it's poor because
28:10 --> 28:11it relies a lot on
28:11 --> 28:13and it assumes that everybody
28:13 --> 28:14has a good
28:14 --> 28:15amount of support at home,
28:15 --> 28:16but there are so many
28:16 --> 28:17patients that we try to
28:17 --> 28:18help that don't have that,
28:18 --> 28:20often through
28:20 --> 28:21no fault of their own.
28:21 --> 28:22And so trying to help
28:22 --> 28:24navigate the system for them
28:24 --> 28:25and help them through
28:25 --> 28:26that can be really hard
28:26 --> 28:28on patients and the teams
28:28 --> 28:29that we help and also
28:29 --> 28:29us.
28:30 --> 28:31Doctor Dmitry Kozhevnikov
28:32 --> 28:33is an assistant professor and
28:33 --> 28:35associate program director of the
28:35 --> 28:37Yale Hospice and Palliative Medicine
28:37 --> 28:38Fellowship at the Yale School
28:38 --> 28:39of Medicine.
28:40 --> 28:41If you have questions, the
28:41 --> 28:43address is cancer answers at
28:43 --> 28:44yale dot e d u,
28:44 --> 28:46and past editions of the
28:46 --> 28:47program are available in audio
28:47 --> 28:49and written form at yale
28:49 --> 28:50cancer center dot org.
28:51 --> 28:52We hope you'll join us
28:52 --> 28:53next time to learn more
28:53 --> 28:54about the fight against cancer.
28:54 --> 28:56Funding for Yale Cancer Answers
28:56 --> 28:58is provided by Smilow Cancer
28:58 --> 28:58Hospital.

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Building Relationships through Outpatient Palliative Care with guest Dr. Dmitry Kozhevnikov April 6, 2025

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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Guests

Dr. Dmitry Kozhevnikov

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