Palliative Care in the Outpatient Setting

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:07Welcome to Yale Cancer
00:07 --> 00:08Answers with your host
00:08 --> 00:10Doctor Anees Chagpar. Yale Cancer
00:10 --> 00:12Answers features the latest
00:12 --> 00:14information on cancer care by
00:14 --> 00:16welcoming oncologists and specialists
00:16 --> 00:18who are on the forefront of the
00:18 --> 00:20battle to fight cancer. This week,
00:20 --> 00:21it's a conversation about palliative
00:21 --> 00:23care with Doctor Dmitry Kozhevnikov.
00:23 --> 00:25Doctor Kozhevnikov is an
00:25 --> 00:28assistant professor at the Yale School
00:28 --> 00:30of Medicine where Doctor Chagpar is
00:30 --> 00:32a professor of surgical oncology.
00:34 --> 00:36So Dimitry, maybe we can start off by
00:36 --> 00:38you telling us a little bit more about
00:38 --> 00:39yourself and what exactly you do.
00:40 --> 00:42I'm an internist by training and a
00:42 --> 00:44palliative care physician, and what
00:44 --> 00:45this means is that after medical school,
00:45 --> 00:48I chose to specialize in internal medicine,
00:48 --> 00:51giving me the training to treat a
00:51 --> 00:54variety of diseases that affect adults.
00:54 --> 00:55After graduation.
00:55 --> 00:57Internists can either pursue work
00:57 --> 00:59in general medicine in the hospital
00:59 --> 01:01or primary care practices,
01:01 --> 01:03or they can continue their training by
01:03 --> 01:05pursuing a fellowship and specialties.
01:05 --> 01:08Some specialties like cardiology,
01:08 --> 01:10infectious disease and many others.
01:10 --> 01:13And I was fascinated by the idea of
01:13 --> 01:15specialty palliative care training.
01:15 --> 01:16Knowing that it would provide me
01:16 --> 01:18with a unique skillset to help
01:18 --> 01:20me provide patient centered,
01:20 --> 01:22compassionate care to patients
01:22 --> 01:23with serious illness.
01:23 --> 01:25Palliative care is a type of
01:25 --> 01:26specialized medical care for people
01:26 --> 01:28living with a serious illness,
01:28 --> 01:30and this type of care is focused
01:30 --> 01:32on providing relief from the
01:32 --> 01:33symptoms of the illness and also
01:33 --> 01:35the stresses that come along with it,
01:35 --> 01:37and the goal really is to
01:37 --> 01:38help people live better.
01:38 --> 01:40It's provided by a specially
01:40 --> 01:42trained team of doctors,
01:42 --> 01:44nurses and many other specialists
01:44 --> 01:46who work together with the
01:46 --> 01:47patients other doctors to provide
01:47 --> 01:48an extra layer of support.
01:49 --> 01:50So you know palliative care
01:50 --> 01:52is one of these things.
01:52 --> 01:55That is a little bit fuzzy.
01:55 --> 01:58I think too many people.
01:58 --> 02:01Some people think of
02:01 --> 02:03palliative care as Hospice.
02:03 --> 02:05Some people think of palliative
02:05 --> 02:08care as pain management.
02:08 --> 02:11Some people think of palliative
02:11 --> 02:14care as death panels.
02:14 --> 02:17And yet palliative care,
02:17 --> 02:19the way that you've described
02:19 --> 02:23it just seems more like a
02:23 --> 02:27part of medical practice.
02:27 --> 02:29So can you help?
02:29 --> 02:31Kind of differentiate it
02:31 --> 02:33from those other things?
02:33 --> 02:35Absolutely. And I always emphasize
02:35 --> 02:38that palliative care is really based
02:38 --> 02:40on the needs of the patient and
02:40 --> 02:42not the prognosis of the disease.
02:42 --> 02:43It's appropriate at any age
02:43 --> 02:45and any stage of an illness,
02:45 --> 02:48and can be provided alongside
02:48 --> 02:49curative treatments.
02:49 --> 02:50Hospice is very different and
02:50 --> 02:52there's a lot of overlap between
02:52 --> 02:53palliative care and Hospice,
02:53 --> 02:55but Hospice is really the benefit
02:55 --> 02:58of that is additional support for
02:58 --> 03:00patients who are living with a
03:00 --> 03:02terminal illness and a prognosis
03:02 --> 03:04many times of less than six months.
03:04 --> 03:07So many of our patients in palliative care,
03:07 --> 03:08especially in our clinic,
03:08 --> 03:10are undergoing treatment for their
03:10 --> 03:12cancer for different lengths of time,
03:12 --> 03:15sometimes many years.
03:15 --> 03:18And while we see our patients in our clinic,
03:18 --> 03:20value of care can also be delivered in
03:20 --> 03:22multiple other settings like hospitals,
03:22 --> 03:24nursing homes or even patients homes.
03:26 --> 03:28And so so it it seems to
03:28 --> 03:30be different than Hospice.
03:30 --> 03:32How is palliative care
03:32 --> 03:34different from pain management?
03:35 --> 03:37Yeah, pain management is certainly one
03:37 --> 03:40of the aspects and domains of medical
03:40 --> 03:42care that we cover in palliative care.
03:42 --> 03:47There's so much to be said about
03:47 --> 03:50physical symptoms that patients undergo
03:50 --> 03:53and experience with their cancer,
03:53 --> 03:57but also non physical symptoms like anxiety,
03:57 --> 03:58depression, insomnia.
03:58 --> 04:01These are all other things that we
04:01 --> 04:04screen for when patients come to see us.
04:04 --> 04:05Pain management is something that.
04:05 --> 04:08There's a strong focus on in the
04:08 --> 04:10training and we're really proud
04:10 --> 04:12of how well we can treat pain,
04:12 --> 04:14especially given what's going
04:14 --> 04:16on in the media with opioids,
04:16 --> 04:18and we know how to do this safely
04:18 --> 04:20and we put in place many measures
04:20 --> 04:23to to make sure that patients are
04:23 --> 04:24getting access to pain treatment
04:24 --> 04:26for their cancer in a safe way.
04:27 --> 04:29But it seems like palliative care
04:29 --> 04:30is more than pain management,
04:30 --> 04:34and it's kind of that extra layer
04:34 --> 04:36of support that you mentioned.
04:36 --> 04:38And and and working with a
04:38 --> 04:40team of doctors and nurses.
04:40 --> 04:44And, you know, often chaplains and
04:44 --> 04:46pharmacists and social workers
04:46 --> 04:51and all kinds of people to really.
04:51 --> 04:53Assess and and help with the needs of
04:53 --> 04:55the patients in many different domains.
04:55 --> 04:56Is that right?
04:57 --> 04:58That's totally right,
04:58 --> 05:00and he's palliative care is way more than
05:00 --> 05:02just the pain management aspect of it.
05:02 --> 05:05We we really do a lot for
05:05 --> 05:07patients from the beginning,
05:07 --> 05:09starting with basically getting to know
05:09 --> 05:11who they are as people outside of their
05:11 --> 05:13medical history and their medical records.
05:13 --> 05:15So what things like what
05:15 --> 05:17is important to them?
05:17 --> 05:18Who is important to them?
05:18 --> 05:19What are their goals?
05:19 --> 05:21What are they looking forward to?
05:21 --> 05:23Because we know that it's only
05:23 --> 05:25once we learn about these vital
05:25 --> 05:28aspects of people's lives that we
05:28 --> 05:30can deliver the best care to them.
05:30 --> 05:32We also know that multidisciplinary care
05:32 --> 05:35has been shown to be more effective
05:35 --> 05:37than when we provide care in silos.
05:37 --> 05:40So when we work together in a
05:40 --> 05:43team of people that have different
05:43 --> 05:46expertise as we do and and many other
05:46 --> 05:47fields have borrowed this as well,
05:47 --> 05:50we find that we can uncover areas
05:50 --> 05:52of distress that we may not have
05:52 --> 05:54found if we just looked at it
05:54 --> 05:56from one narrow point of view.
05:57 --> 05:59And so you know Dimitri.
05:59 --> 06:01Some may push back and say,
06:01 --> 06:04you know you talk about palliative care.
06:04 --> 06:06Is providing the best quality of care
06:06 --> 06:08for patients in a multidisciplinary
06:08 --> 06:11approach and getting to know the patient
06:11 --> 06:13beyond their medical diagnosis to kind
06:13 --> 06:15of take care of the whole patient.
06:15 --> 06:17But some may push back and say, well,
06:17 --> 06:19I thought that's what doctors do I.
06:19 --> 06:21I thought that doctors you know are
06:21 --> 06:24supposed to get to know me as a patient
06:24 --> 06:26and and treat the whole patient.
06:26 --> 06:28Why do I need palliative care?
06:28 --> 06:31Why can't my doctor?
06:31 --> 06:34Who's managing my illness?
06:34 --> 06:35Whatever that illness may be,
06:35 --> 06:37cancer or anything else?
06:37 --> 06:40Do all of the things that you do.
06:41 --> 06:42I'm glad you brought that up in Nice
06:42 --> 06:44and one of the big challenges that we
06:44 --> 06:46face is that there simply aren't enough
06:46 --> 06:48palliative care specialists to care for
06:48 --> 06:50all of patients with serious illness.
06:50 --> 06:53One study in 2017 highlighted something
06:53 --> 06:56pretty startling that there's estimated
06:56 --> 06:591 oncologist for every 140 newly
06:59 --> 07:01diagnosed cancer patients in the US.
07:01 --> 07:03But there's only about 1 palliative
07:03 --> 07:05care physician for every 1200
07:05 --> 07:07patients with serious illness,
07:07 --> 07:10so this projected growth also looking
07:10 --> 07:13forward, is only about 1% for.
07:13 --> 07:14Of palliative care specialists
07:14 --> 07:16over the next 20 years,
07:16 --> 07:18so one of the main things and one
07:18 --> 07:20of the focuses that we have in our
07:20 --> 07:23work is to teach these skills to our
07:23 --> 07:25colleagues in other areas of medicine,
07:25 --> 07:27like primary care,
07:27 --> 07:28critical care,
07:28 --> 07:29oncology and and other specialties
07:29 --> 07:32so they can help us address all of
07:32 --> 07:33these needs that we as a nation
07:33 --> 07:35faced with serious illness and
07:35 --> 07:37the palliative care specialists
07:37 --> 07:39like us can be called in to help
07:39 --> 07:41in situations which would benefit
07:41 --> 07:44from a higher level of expertise.
07:44 --> 07:45So like you said,
07:45 --> 07:47you know I encourage everyone to
07:47 --> 07:49ask whether palliative care is
07:49 --> 07:51available to you and if it is,
07:51 --> 07:52please take advantage of it.
07:52 --> 07:54If if you aren't sure if it's available,
07:54 --> 07:55then ask your medical team.
07:56 --> 07:59And so, how do you know if you're a patient?
07:59 --> 08:01I mean, because the way that
08:01 --> 08:03you describe palliative care,
08:03 --> 08:04it seems like everybody
08:04 --> 08:05should want palliative care.
08:05 --> 08:06Even if they were, you know,
08:06 --> 08:09especially not at the end of
08:09 --> 08:11a terminal illness, right?
08:11 --> 08:13You mentioned that palliative care
08:13 --> 08:16is something that can be used in
08:16 --> 08:17addition to curative approaches,
08:17 --> 08:19that it kind of takes care of the
08:19 --> 08:21whole patient that it looks at what
08:21 --> 08:23your needs are in various domains.
08:23 --> 08:24It seems like that should
08:24 --> 08:26be something that everybody.
08:26 --> 08:30Should want as part of standard medical care.
08:30 --> 08:33So how do you know when palliative
08:33 --> 08:35care is something that you
08:35 --> 08:38particularly need or this higher
08:38 --> 08:40end palliative care where you need
08:40 --> 08:42a palliative care specialist?
08:44 --> 08:45I think that palliative care can
08:45 --> 08:47be introduced to a patient at
08:47 --> 08:49any stage of a serious illness.
08:49 --> 08:50You know starting at diagnosis,
08:50 --> 08:52but one of the challenges is trying
08:52 --> 08:55to figure out when palliative
08:55 --> 08:58care support is most helpful,
08:58 --> 09:00and I think the studies that are
09:00 --> 09:02being done now and and in the
09:02 --> 09:04future are really kind of trying
09:04 --> 09:06to figure out the optimal timing
09:06 --> 09:08of referral to palliative care.
09:08 --> 09:10So what I would say is that anyone
09:10 --> 09:12is eligible for palliative care
09:12 --> 09:14services with a serious illness.
09:14 --> 09:18From diagnosis throughout any point,
09:18 --> 09:19but what makes most sense,
09:19 --> 09:21especially because it's an extra
09:21 --> 09:22visit and it's an extra team.
09:22 --> 09:25What makes the most sense is really
09:25 --> 09:27when patients have symptoms that
09:27 --> 09:30are burdensome that aren't being.
09:30 --> 09:32That aren't being managed or have
09:32 --> 09:34opportunities to manage better,
09:34 --> 09:37and these symptoms are interfering
09:37 --> 09:39with their day-to-day function
09:39 --> 09:42and what they want to actually
09:42 --> 09:43achieve with their goals.
09:45 --> 09:47And so so talk a little bit more about
09:47 --> 09:49the kinds of patients that you see and
09:49 --> 09:51the kinds of symptoms that you treat.
09:51 --> 09:53Because I can imagine that many
09:53 --> 09:54people are listening to this
09:54 --> 09:56kind of saying to themselves.
09:56 --> 09:59Well, you know, it sounds really great,
09:59 --> 10:01but I really don't know
10:01 --> 10:04still what what it entails.
10:04 --> 10:06I mean when you say symptoms,
10:06 --> 10:08do you mean things like you know
10:08 --> 10:10why I underwent chemotherapy,
10:10 --> 10:11and my hair fell out,
10:11 --> 10:14and that was really problematic for me?
10:14 --> 10:16Or do you mean?
10:16 --> 10:19Psychosocial distress where you know I
10:19 --> 10:23was going through a cancer journey and
10:23 --> 10:25found that some of the relationships
10:25 --> 10:28that I thought I had were not as
10:28 --> 10:30strong as they might have been.
10:30 --> 10:34Or maybe it's financial distress is the
10:34 --> 10:37thing that is most problematic to me.
10:37 --> 10:40You talked a little bit about pain control.
10:40 --> 10:43Tell us a little bit more about
10:43 --> 10:45what exactly it is that you do.
10:46 --> 10:49Yeah, so palliative care teams screen
10:49 --> 10:52for common symptoms that are seen
10:52 --> 10:54within the populations that they treat.
10:54 --> 10:56So for example, at Smilow Cancer
10:56 --> 10:59Hospital in our palliative care team,
10:59 --> 11:01we assess patients for common
11:01 --> 11:04symptoms like in addition to pain,
11:04 --> 11:06nausea, fatigue, insomnia,
11:06 --> 11:09mood issues like anxiety and
11:09 --> 11:12depression and existential distress,
11:12 --> 11:14and all of these could either be
11:14 --> 11:16coming from the cancer itself.
11:16 --> 11:19Or from the treatment that is
11:19 --> 11:22being given for the cancer so.
11:22 --> 11:25You know when we run into things like
11:25 --> 11:26spiritual distress and and actually
11:26 --> 11:29screen for them proactively and financial
11:29 --> 11:31distress like you mentioned we are.
11:31 --> 11:33If we find that the earlier that we
11:33 --> 11:34uncover these sources of distress,
11:34 --> 11:36the better we can provide support
11:36 --> 11:38to address them and also make
11:38 --> 11:40it much easier for patients to
11:40 --> 11:42get through their treatments,
11:42 --> 11:43which is our optimal goal.
11:44 --> 11:47So, you know, I can imagine that.
11:47 --> 11:50Well, let me ask you this.
11:50 --> 11:53In in, in cancer centers,
11:53 --> 11:56it seems to me that not all
11:56 --> 11:58cancer patients would be offered.
11:58 --> 12:01Palliative care is particularly given.
12:01 --> 12:05The paucity of of availability of palliative
12:05 --> 12:08care specialists as you mentioned.
12:08 --> 12:12So is that something that?
12:12 --> 12:14Should be routine that every
12:14 --> 12:16cancer patient should at least be
12:16 --> 12:18introduced to palliative care.
12:18 --> 12:22Or is it something where?
12:22 --> 12:25You you would recommend that only
12:25 --> 12:29when a primary care team or medical
12:29 --> 12:33team cannot manage particular issues.
12:33 --> 12:34Palliative care is called in.
12:35 --> 12:36An ideal world.
12:36 --> 12:39I really wish that every cancer patient
12:39 --> 12:41could be introduced to palliative care
12:41 --> 12:44team and that would be really wonderful.
12:44 --> 12:45Model of care and that's something.
12:45 --> 12:48Maybe we can strive towards at
12:48 --> 12:50least screening for the patients
12:50 --> 12:52that would be highest would benefit
12:52 --> 12:54the most from palliative care.
12:54 --> 12:57What we find is that we just end
12:57 --> 12:59up working together with the
12:59 --> 13:01patient's primary medical team
13:01 --> 13:04to figure out what issues are.
13:04 --> 13:06Well, sort of fall within.
13:06 --> 13:08The primary palliative care skill
13:08 --> 13:10center or skills that everyone in
13:10 --> 13:12medicine should have and which ones
13:12 --> 13:14require a little bit more expertise
13:14 --> 13:17and and those are the patients that
13:17 --> 13:19we really love to to be involved with.
13:19 --> 13:19Because you know,
13:19 --> 13:21you know we were so proud of the
13:21 --> 13:23training that we have and also the
13:23 --> 13:24interdisciplinary team that we have
13:24 --> 13:26to address. Much of these things.
13:26 --> 13:28You know what?
13:28 --> 13:30As you talk about palliative care
13:30 --> 13:32and all of the things that you do.
13:32 --> 13:35I think about people who may be
13:35 --> 13:37getting care out in the community
13:37 --> 13:40where there are not these resources
13:40 --> 13:42and after we come back from taking
13:42 --> 13:45a brief break for a medical minute,
13:45 --> 13:47I want to talk about how those
13:47 --> 13:49people can get kind of palliative
13:49 --> 13:51care where they live as well.
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15:12 --> 15:14Welcome back to Yale Cancer Answers.
15:14 --> 15:16This is doctor Anees Chagpar and
15:16 --> 15:19I'm joined tonight by my guest
15:19 --> 15:20Doctor Dmitry Kozhevnikov.
15:20 --> 15:22We are learning about the field of
15:22 --> 15:24palliative care in the outpatient
15:24 --> 15:26setting and right before the break
15:26 --> 15:30you were talking a
15:30 --> 15:33lot about palliative care and the fact
15:33 --> 15:36that there is a nationwide paucity of
15:36 --> 15:39palliative care specialists that really
15:39 --> 15:42palliative care in the ideal world.
15:42 --> 15:44Would be introduced to every patient
15:44 --> 15:47who had a critical illness and that
15:47 --> 15:50this really is much more than simply
15:50 --> 15:53Hospice or pain control in this
15:53 --> 15:56country we have people being diagnosed
15:56 --> 16:00every day in every center in America,
16:00 --> 16:02and some of those are blessed
16:02 --> 16:04to be large academic centers.
16:04 --> 16:07But there are people who are being
16:07 --> 16:09diagnosed in smaller centres and yet
16:09 --> 16:13they may have some of the same symptoms.
16:13 --> 16:16Issues and other crises of other
16:16 --> 16:17cancer patients.
16:17 --> 16:19In some of these smaller centers
16:19 --> 16:22they will try to piece together a
16:22 --> 16:24palliative care team that's not
16:24 --> 16:27really called palliative care.
16:27 --> 16:30They might bring in a pain management
16:30 --> 16:33specialist from anesthesia to deal with pain.
16:33 --> 16:36They might have a social worker
16:36 --> 16:38to deal with financial issues
16:38 --> 16:40and psychosocial distress.
16:40 --> 16:43They may have a chaplain to deal with.
16:43 --> 16:47Existential crises and and this.
16:47 --> 16:50Issue of of spirituality that
16:50 --> 16:53some cancer patients face.
16:53 --> 16:55What are your thoughts on on that?
16:55 --> 16:57It is that helpful for patients
16:58 --> 17:00you know. Palliative care has been one of
17:00 --> 17:01the fastest growing fields in medicine,
17:01 --> 17:04as so many patients, clinicians,
17:04 --> 17:07payers and policymakers are really
17:07 --> 17:09recognized its potential to improve quality
17:09 --> 17:12of care for patients with serious illness.
17:12 --> 17:14Unfortunately, we're still at a place
17:14 --> 17:16where there are areas in the country that
17:16 --> 17:18don't have access to palliative care,
17:18 --> 17:20and I think that's where advocacy
17:20 --> 17:22comes in within our field,
17:22 --> 17:23especially with recent legislation.
17:23 --> 17:26That is being worked on to attack this
17:26 --> 17:29issue from multiple angles, number one,
17:29 --> 17:31increase the funding for education
17:31 --> 17:33of palliative care specialists.
17:33 --> 17:37Also, not only product care specialists
17:37 --> 17:39but also general primary care,
17:39 --> 17:42palliative skills that any clinician should
17:42 --> 17:47have and #2 increase ways that we can.
17:47 --> 17:50You know really promote health care system
17:50 --> 17:54that rewards us for the quality of care.
17:54 --> 17:57That we can give to our patients
17:57 --> 17:59rather than rewarding us for the
17:59 --> 18:01number of patients that we see.
18:01 --> 18:03And so you know, despite this growth,
18:03 --> 18:04you know.
18:04 --> 18:04Unfortunately,
18:04 --> 18:06there are still barriers to accessing
18:06 --> 18:08palliative care for millions of patients,
18:08 --> 18:11and this really varies by hospital
18:11 --> 18:13size and geography and staffing.
18:13 --> 18:15But what I would say is that
18:15 --> 18:16the interdisciplinary approach
18:16 --> 18:16that you mentioned,
18:16 --> 18:19even if there isn't a official palliative
18:19 --> 18:22care team that's been well developed yet.
18:22 --> 18:23That's a start,
18:23 --> 18:24and I think that.
18:24 --> 18:26That's a really step in the right direction.
18:26 --> 18:29When do you think patients who may be
18:29 --> 18:33at a smaller center and maybe getting
18:33 --> 18:36kind of this piecemeal palliative
18:36 --> 18:40care ought to ask for referral to
18:40 --> 18:44a larger Center for a particular
18:44 --> 18:46palliative care consultation?
18:46 --> 18:47Is that something that people
18:47 --> 18:49should be thinking about,
18:49 --> 18:52or is that not really something that is done
18:53 --> 18:55well? I can't speak for.
18:55 --> 18:57All the programs across the country.
18:57 --> 18:59But what I can say is that it's
18:59 --> 19:02quite challenging for a program to
19:02 --> 19:04take on patients from outside the
19:04 --> 19:06system unless the patient's already
19:06 --> 19:09getting care within that system.
19:09 --> 19:11So I think that comes down to
19:11 --> 19:13a continuity of care issue.
19:13 --> 19:16It's so helpful for us to work so closely
19:16 --> 19:18with our colleagues here and oncology,
19:18 --> 19:20and the outpatient setting and then
19:20 --> 19:23all of the other specialties in the
19:23 --> 19:25hospital because we all just communicate.
19:25 --> 19:26Very smoothly,
19:26 --> 19:29we all know the patient and it really
19:29 --> 19:31promotes this patient centered care.
19:31 --> 19:34I think the best way to approach that
19:34 --> 19:37issue is really to for physicians,
19:37 --> 19:39nurses, nurse practitioners,
19:39 --> 19:42and others within each system
19:42 --> 19:44health care system.
19:44 --> 19:47Local system to really advocate for this
19:47 --> 19:50kind of support for their patients,
19:50 --> 19:53and that that might really make the
19:53 --> 19:55difference over the long term and leadership.
19:55 --> 19:58Putting resources towards dedicated
19:58 --> 20:01palliative care teams that can,
20:01 --> 20:01you know,
20:01 --> 20:02add an extra layer of support
20:03 --> 20:07and you know to that end.
20:07 --> 20:09All of the health care administrators
20:09 --> 20:12who are are listening to us are thinking,
20:12 --> 20:14yes, that's yet another expense.
20:14 --> 20:20In an already very tight healthcare system.
20:20 --> 20:23So talk to us a little bit more
20:23 --> 20:26about evidence based outcomes of
20:26 --> 20:29palliative care services and whether
20:29 --> 20:34there is in fact data that supports.
20:34 --> 20:35Valuative care services.
20:35 --> 20:38As improving quality of care,
20:38 --> 20:41perhaps longevity does it.
20:41 --> 20:45And and and even further,
20:45 --> 20:48is there any evidence for
20:48 --> 20:49its cost effectiveness?
20:50 --> 20:51Yeah, we have some fascinating
20:51 --> 20:53evidence to support the early
20:53 --> 20:54involvement of palliative care,
20:54 --> 20:56particularly in oncology patients,
20:56 --> 20:59but in other diseases as well,
20:59 --> 21:01and one of the pivotal studies in
21:01 --> 21:03our field was published in the New
21:03 --> 21:05England Journal of Medicine in 2010.
21:05 --> 21:07And this was led by our colleagues at mass,
21:07 --> 21:10general Doctor Temel and her team,
21:10 --> 21:11and the researchers recruited
21:11 --> 21:13a group of patients with lung
21:13 --> 21:15cancer who volunteered to be
21:15 --> 21:17randomized to two different groups.
21:17 --> 21:19One group received standard oncology
21:19 --> 21:22care and the other group that comparison
21:22 --> 21:25group received standard oncology care
21:25 --> 21:27plus early palliative care and what
21:27 --> 21:28they found was sort of incredible.
21:28 --> 21:31The patients in the early palliative
21:31 --> 21:33care group had better symptom control.
21:33 --> 21:35They had better mood.
21:35 --> 21:37Better quality of life scores and
21:37 --> 21:40they had less intensive care at
21:40 --> 21:42the end of life and they also lived
21:42 --> 21:44on average two months longer than
21:44 --> 21:47the patients who did not have any
21:47 --> 21:48exposure to palliative care.
21:48 --> 21:51And this was really a huge a-ha moment
21:51 --> 21:54for our field when we really could
21:54 --> 21:57demonstrate the specific benefits
21:57 --> 21:58of palliative care involvement
21:58 --> 22:00when it comes to things that really
22:00 --> 22:00matter to patients
22:01 --> 22:04and so with that less intense use
22:04 --> 22:06of resources at the end of life.
22:06 --> 22:09Did that study or any other study demonstrate
22:09 --> 22:12cost effectiveness of palliative care?
22:12 --> 22:15In other words, was there an offset in
22:15 --> 22:19terms of the cost of hiring palliative
22:19 --> 22:22care specialists versus the cost
22:22 --> 22:25of treatments at the end of life,
22:25 --> 22:27which may not have been helpful?
22:28 --> 22:30Yeah, there's some really strong
22:30 --> 22:33data to support the the support the
22:33 --> 22:35resources of having a palliative
22:35 --> 22:37care team in the hospital.
22:37 --> 22:40Which has shown in multiple different
22:40 --> 22:41studies to minimize healthcare
22:42 --> 22:44utilization at the end of life,
22:44 --> 22:46which saves the system money.
22:46 --> 22:49But that's not really what we focus on,
22:49 --> 22:50and that's that's not the
22:50 --> 22:51most important part of this.
22:51 --> 22:52The the real important part
22:52 --> 22:55of this is that we align,
22:55 --> 22:57we align what's important to the patients
22:57 --> 22:59with what the care that they receive is.
22:59 --> 23:01So, for example,
23:01 --> 23:05patients who want to spend whatever time they
23:05 --> 23:07have at home and not be in the hospital.
23:07 --> 23:08Back and forth.
23:08 --> 23:09Yeah, you know which obviously
23:09 --> 23:11is a burden to a lot of people.
23:11 --> 23:14Those patients receive care
23:14 --> 23:16that is aligned with that,
23:16 --> 23:19and that's that's really our motivation
23:19 --> 23:21and our daily focus and rewarding
23:21 --> 23:23nature of this of this field.
23:24 --> 23:26Yeah no, I get that completely Dimitri.
23:26 --> 23:27But the healthcare administrators
23:27 --> 23:30who are looking at hiring palliative
23:30 --> 23:32care specialists and are thinking
23:32 --> 23:35about the additional cost of doing
23:35 --> 23:38so are often also thinking about.
23:38 --> 23:39It's cost effectiveness,
23:39 --> 23:42so it's nice when you can provide
23:42 --> 23:45evidence that not only does palliative
23:45 --> 23:48care align with patients interests,
23:48 --> 23:51but it also aligns with the
23:51 --> 23:53healthcare systems interests in
23:53 --> 23:56terms of reducing health care costs,
23:56 --> 23:59while at the same time improving quality.
23:59 --> 24:03So the next question I have is this.
24:03 --> 24:06You know you did a fellowship in
24:06 --> 24:09palliative care in order for.
24:09 --> 24:11A health care system to provide
24:11 --> 24:13palliative care services.
24:13 --> 24:15Do they need fellowship trained
24:15 --> 24:17palliative care specialists like
24:17 --> 24:21you or is it possible for them to
24:21 --> 24:24train up their existing workforce?
24:24 --> 24:27Whether it's nurses or physicians
24:27 --> 24:30to provide them some palliative
24:30 --> 24:33care training that so that they may
24:33 --> 24:37be able to provide these kinds of
24:37 --> 24:39resources to their patients without.
24:39 --> 24:40Uhm,
24:40 --> 24:42going through a fellowship training
24:42 --> 24:45or hiring somebody who who has
24:45 --> 24:47fellowship training in palliative care.
24:49 --> 24:51Yeah, the the standard of care
24:51 --> 24:54really is to have board certified
24:54 --> 24:58palliative care physicians on the team.
24:58 --> 24:59But that being said,
24:59 --> 25:02there are many ways that health care
25:02 --> 25:05systems can invest in their current
25:05 --> 25:08staff by providing training for,
25:08 --> 25:10for example, the nurses in the
25:10 --> 25:12hospital taking care of patients on
25:12 --> 25:15different in different settings and
25:15 --> 25:17whether it's in middle critical care
25:17 --> 25:20unit or on the normal regular floor.
25:20 --> 25:22Investing in them to provide
25:22 --> 25:25training on the primary palliative
25:25 --> 25:28care skills that could really help
25:28 --> 25:31them provide aligned care and in
25:31 --> 25:33really patient centered care at all
25:33 --> 25:35levels and all stages of disease.
25:35 --> 25:37And so obviously we would
25:37 --> 25:40all love to have you know,
25:40 --> 25:41board certified physicians
25:41 --> 25:44on staff and but you know,
25:44 --> 25:45that's really been a challenge
25:45 --> 25:47and I think it's going to be
25:47 --> 25:48a challenge looking forward.
25:48 --> 25:50I think we can address that through.
25:50 --> 25:51And investing in other ways,
25:52 --> 25:54and so you know you.
25:54 --> 25:56You mentioned that palliative care can
25:56 --> 25:58be offered in a variety of settings,
25:58 --> 26:01so certainly in the critical care units
26:01 --> 26:03on the oncology units in the hospital.
26:03 --> 26:06But your main area is is
26:06 --> 26:08in the outpatient clinic.
26:08 --> 26:09Is that right?
26:09 --> 26:12And can you tell us a little bit more
26:12 --> 26:15about how palliative care differs from
26:15 --> 26:18inpatient services to outpatient?
26:20 --> 26:22So I'm I'm I'm lucky enough to actually
26:22 --> 26:25have a few weeks a year where I'm
26:25 --> 26:27working in the hospital with our
26:27 --> 26:29inpatient palliative care team as well,
26:29 --> 26:31so I'm able to see patients both in
26:31 --> 26:34the clinic setting and then also help
26:34 --> 26:36them when they're in the hospital
26:36 --> 26:38with an acute issue and that there
26:38 --> 26:41is a lot of overlap between the work
26:41 --> 26:43that we do in the clinic and the
26:43 --> 26:45work that we do in the hospital.
26:45 --> 26:47One of the beautiful things is
26:47 --> 26:49that when one of our patients,
26:49 --> 26:51you know we know and and they
26:51 --> 26:53know us has an issue and they're
26:53 --> 26:54admitted to the hospital,
26:54 --> 26:57they have a team that already knows them
26:57 --> 26:59and has the developed a relationship with
26:59 --> 27:01them to comment and check in on them.
27:01 --> 27:03See what's going on.
27:03 --> 27:06See if there unaddressed symptoms or
27:06 --> 27:08other aspects of their palliative
27:08 --> 27:11care needs that we could add onto.
27:11 --> 27:13So what the primary medical team is doing?
27:13 --> 27:15The main difference is really
27:15 --> 27:16between the two settings.
27:16 --> 27:20Is that obviously in the outpatient setting?
27:20 --> 27:22We're able to develop relationships
27:22 --> 27:24over longer periods of time,
27:24 --> 27:25and and that really is is
27:25 --> 27:26very rewarding to me.
27:27 --> 27:30And presumably the other issue is
27:30 --> 27:32that going back to something that
27:32 --> 27:34you mentioned before the break,
27:34 --> 27:36you know not all of these
27:36 --> 27:38patients that you see,
27:38 --> 27:40particularly in the outpatient setting,
27:40 --> 27:43are quote at the end of life.
27:43 --> 27:46So some of these may be, you know,
27:46 --> 27:48dealing with symptoms that they may
27:48 --> 27:51have developed a undergoing active
27:51 --> 27:53treatment for curative intent,
27:53 --> 27:54and you're you're kind of
27:54 --> 27:56seeing them through that process
27:56 --> 27:58where they're able to come to.
27:58 --> 28:01An outpatient clinic and avail
28:01 --> 28:02themselves of your service.
28:02 --> 28:03Is that right?
28:04 --> 28:05Yeah, so many of our patients are
28:05 --> 28:08with us for years and years and they
28:08 --> 28:09are living with serious illness.
28:09 --> 28:12For example, cancers like breast
28:12 --> 28:14cancer with which have which have
28:14 --> 28:16amazing treatments that are coming
28:16 --> 28:18out over the last few years,
28:18 --> 28:19really impacting patients lives
28:19 --> 28:21and allowing them to live longer.
28:21 --> 28:25And other hematologic cancers, for example,
28:25 --> 28:27are are more like chronic illnesses
28:27 --> 28:29that people live with for a long time, so.
28:29 --> 28:31We've really found our niche in
28:31 --> 28:32helping those patients live better.
28:33 --> 28:34Doctor Dmitry Kozhevnikov
28:34 --> 28:36is an assistant professor at
28:36 --> 28:38the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the addresses cancer answers at
28:42 --> 28:44yale.edu and past editions of the
28:44 --> 28:47program are available in audio and
28:47 --> 28:48written form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:54cancer here on Connecticut Public
28:54 --> 28:56radio funding for Yale Cancer Answers
28:56 --> 29:00is provided by Smilow Cancer Hospital.

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March 6, 2022

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