The TEAM* approach to palliative care
How oncologists can integrate palliative care into
their practiceThomas J. Smith, MD FACP FASCO FAAHPM
Director of Palliative Medicine
Harry J. Duffey Family Professor of Palliative Medicine
Professor of Oncology
Johns Hopkins Medical Institutions
tsmit136@jhmi.edi*Time, Education, Assessment, Management
June 17, 20171

Disclosure – Tom Smith• Received $5100 in travel expenses to teach at a course
sponsored by the makers of MC5A Scrambler Therapy
Machine, January 2017
– Business class air fare to Seoul, Korea– Hotel and meals– $38 vase for spouse• Up To Date, Editor, Palliative Care, non-pain symptoms(With Eduardo Bruera)• ABIM Hospice and Palliative Medicine test writing
committee so no disclosure of questions or answers
June 17, 20172

Take Home Messages – Tom Smith
1. Partner with a palliative care team that you trust. Create
space in your office for PC help. Unless you can spare anhour a month.
2. Set up a Hospice Information Visit when you think theperson has 6-12 months to live, to ensure that “this will bea planned transition, to hospice, if and when you need it.”
3. At each CT or scan showing progression ask “Would you
like to discuss what this means?”– Gives them control over the information.
– You know the situation has changed for them but they don’t know theconsequences.
– Don’t just go on to “The next chemo will be ____________.”
June 17, 20173

Definition of Hospice• Pioneered in the 1950s by Dame
Cicely Saunders.
• Hospice is a type and philosophy ofcare that focuses on the palliation ofa terminally ill patient's symptoms.
• When there are no longer curativeoptions, or reasonable options.
• Hospice reimbursement is set at$160 a day, so all expenses must becovered from this.

June 17, 20174

Definition of palliative care
“Palliative care is specialized medical care for people withserious illnesses. This type of care is focused on providing
patients with relief from the symptoms, pain, and stressof a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and thefamily.
Palliative care is provided by a team of doctors, nurses, andother specialists who work with a patient's other doctors toprovide an extra layer of support.
Palliative care is appropriate at any age and at any stage in aserious illness, and can be provided together withcurative treatment.”– Diane Meier, MD, Director, Center to Advance Palliative Care
June 17, 20175

Summary of 11 recent studies comparing usual care to UC + PC
StudySurvival

Patient Experience
C=caregiver

Cost

Brumley, 2007 (1/3 ca)=+++ (↑ satisfaction, home-$7550-$4885=resource use

Gade, 2008 (1/3 ca)=deaths, hospice)+++ (↓ ICU, ↑hospice)

Bakitas 2009 (Cancer)

Longer, 5.5 mon, NS+++ (better sx, lessTemel 2010 (lung ca)

Longer, 2.7 mon, S+++ (2x less depression)-$2000

Higginson 2012 (MS)=+++++ (5 sxs better) C+-$2700/12 wks

Zimmermann, 2014 (Cancer)=+++, C+

=Higginson 2014 (dyspnea, mostcancer)

Longer, 15/100 at 1000days
= for lung ca+++=Farquhar 2014 (breathlessness)=+++ (less distress due toBreathlessness) C+

Sidebottom, 2015 (CHF)=+++, C+-$325 for cancer,
better QOL
Dominates costeffectiveness=Bakitas 2015 (Ca)Longer, 6.5 mon, S=QOL, C+ ↓depression,= resource use

Longer 6 mons, NSLonger, 5 months, NS=QOL+, C+= resource use==↓ depression and anxiety,C+Not reportedFerrell, 2015 (Lung Ca)
Grudzen, 2016 (ca patients in ED)
El-Jawahri, 2016 (BMT)
June 17, 2017depression)↓stress,6Bakitas, El-Jawahri, Ferrell, Farguhar, Grudzen, Higginson, Temel, Smith, Zimmermann. JOP in press

ASCO now strongly recommends
concurrent palliative care

• For every advanced cancer patient, based on the evidence– By an interdisciplinary team– Concurrent with oncology care
– Within 8 weeks of diagnosis• The data are not sufficient to say if Oncologists can do this ourselves• http://ascopubs.org/doi/full/10.1200/JCO.2016.70.1474• http://www.asco.org/sites/new-www.asco.org/files/content-files/practiceand-guidelines/documents/2016-palliative-care-checklist.pdf
June 17, 20177

Palliative care has a positive financial impact on theinstitution – and reduces public health spending

The total positive
financial impact of thePC program for 2015
was $3,488,863.17.
Isenberg S, et al. J Onc Practice
DOI: 10.1200/JOP.2016.014860;
published online ahead of print atjop.ascopubs.org on February 28,
2017

June 17, 20178

Palliative Care has a good impact on the health system this FY (estimates)

Financial impact

Cases/year
projected
2016

IP PCU Margin (1)Contribution($/year)FinancialImpact
per case

5 year total
Contribution$

100,000$

500,000

IP PCU Cost $1595 savings/transfer (2)154$1,595 $245,630$

1,228,150

PC IP Consult Cost Savings per Case, $2,374 for patientsdischarged alive (3)1355$2,374 $3,216,770$

16,083,850

PC IP Consult Cost Savings per Case, $6,871 fordecedents, 11% died (4)167$6,871 $

1,147,457$

5,737,285

JHFAU vetted savings$4,709,857$23,549,285

Early PC OP Consult Cost Savings per case (5)$5198/case297$5,198 $245,630$

34,355,000

Hospice referrals Cost Savings per case, $3400/case (6)Assumes half of the actual savings of $6800

800$3,400 $2,720,000$

13,600,000

Professional fees, 50% collection rate (7)$500,000$

2,500,000

Improvement in HCAHPS (2% of Medicare reimbursementin 2017).

?

8,175,487$

74,004,285

Increased ICU bed availability leading to revenue
Reduction in 30 day readmissions?

Goodwill; impact on disparities?

Total impact$Isenberg SA, et al. J Oncol Pract. 2017 Feb 28:JOP2016014860?

Palliative care meets cost-effectiveness criteria andcould spend up to $716 a day more
Cost minimization savings$452 per patient per day
PC inpatient program could
generate 3.11 qualityadjusted life years (QALYs)
from patients (0.05 QALY)
and caregivers (3.06QALYs).
Isenberg S, et al. J Onc Practice 2017
DOI: https://doi.org/10.1200/JOP. 2016.018036;

June 17, 2017

Could spend up to $716 per
patient per day and still
meet cost effectivenesscriteria.
10Palliative Care fastest growing specialty
getpalliativecare.org
90% of >300 bed
hospitals

2006: ABMS
2012: fellowship
required

www.CAPC.org
June 17, 201711

There are major workforce shortages• Should see ~8% of adult discharges• About 3.4% of adult discharge are seen by palliative care
• 1-1.8 MILLION patients are not seen by palliative care
• www.capc.org• 1 hour of PC per month for each of 600,920 cancer deaths
would equal 6000 Full Time Equivalents in PC• 120 fellowship slots a year
• Always referring to PC risks “deskilling oncologists”• We have to learn to do this ourselves• Schenker Y, Arnold R. Toward Palliative Care for All Patients With
Advanced Cancer. JAMA Oncol. 2017 May 18. doi:
10.1001/jamaoncol.2017.1059.
June 17, 201712

Am I doing Palliative Care?

Score 6 or more =good palliative care.

Do I …

Example

ALWAYS ask -What is your understanding of your disease?
How do you like to get medical information?
What is important to you?
What are you hoping for?

1
1
1
1

Multidimensional
symptom assessment

ESAS, MDASI, MSAS, CAPC tool

1

Assessment fordepression

Are you depressed?

1

Screening for delirium

Single question or instruments?

1

Documented goals ofcare discussion

What is your understanding of your disease, nowthat we have reviewed it?

1

Spiritual assessment

Is religion or spirituality important to you?

1

Have I asked about
advance directives

In at least 90% of my seriously patients1

Do I have a “codestatus” discussion
documented

In at least 50% of my seriously ill patients1

June 17, 2017

Points13

Program data: GBM patients
Kuchinad K, et al. J Neurooncol. 2017 May 20. doi: 10.1007/s11060-017-2487-8

Table 2: some NQF/QOPI measures

June 17, 201714

TEAM Concept in Palliative CareTime:• at least an extra hour a month. Every month. Not once.
• Does not have to be the doctor. Advance practicenurses are as good. Oncologists cannot do with a 12
minute visit concentrating on chemo doses.
• Can be in person (Temel, Zimmerman, Ferrell,Higginson, others)• Or by phone/telemedicine (Bakitas ENABLE II and III).
• But structured, an hour a month.

June 17, 2017

15TEAM Concept in Palliative Care
Jacobsen J. Components of early
outpatient palliative care consultation inpatients with metastatic nonsmall celllung cancer. J Palliat Med. 2011
Apr;14(4):459-64. doi:
10.1089/jpm.2010.0382.

“Coping” notes were absent from theOncologists written record
55 minutes
June 17, 2017

Jorgenson A, Sidebottom AC, Richards H,Kirven J. A Description of Inpatient PalliativeCare Actions for Patients With Acute HeartFailure. Am J Hosp Palliat Care. 2016
Nov;33(9):863-870.
• Median 55 minutes• Orders written for 24%, mostly for pain meds
• Recs to change care made for 40%• Some element of ACP in 99%• 79% just one PC visit; 21% two or more
• PC SW 10%, PC Chaplain 5%• PC introduced Advance Care Planning(ACP; 41.6%)••

All 5 major symptoms got better (pain,dyspnea, sleep, etc.)
Quality of Life got better
16

TEAM Concept in Palliative Care
Education:• We don’t educate very well. 2/3s of people think they can be cured
with palliative treatments.
–––••

Weeks JC, Patients' expectations about effects of chemotherapy for advanced cancer. NEngl J Med. 2012 Oct 25;367(17):1616-25.
Chen AB, Expectations about the effectiveness of radiation therapy among patients with
incurable lung cancer. J Clin Oncol. 2013 Jul 20;31(21):2730-5.
Kim Y, Pawlik TM. Patient perceptions regarding the likelihood of cure after surgicalresection of lung and colorectal cancer. Cancer. 2015 Oct 15;121(20):3564-73. doi:
10.1002/cncr.29530. Epub 2015 Jun 19.

“Prognostic awareness” (being able to admit potential life ending illness)requires direct communication by the health care provider.
In Temel’s lung cancer trial, chance of IV chemo in the last month was 9%in the PC group that had good prognostic awareness, versus 55% in usualcare group.
–Jackson VA, Jacobsen J, Greer JA, Pirl WF, Temel JS, Back AL. The cultivation of prognostic awareness through theprovision of early palliative care in the ambulatory setting: a communication guide. J Palliat Med. 2013 Aug;16(8):894900.17,
doi:10.1089/jpm.2012.0547. PMID: 23786425
June201717TEAM Concept in Palliative CareEducation:•••••

Symptom management
Communication with the health care teamOffering only REALISTIC options for treatment
Advance care planning. Recent data suggests DPMA does not make any
difference – has to be Living Will or Advance Directive.
“I am worried about you, and what might happen in the future. I would
like to talk about where we are with the cancer (or heart disease, ordementia).”

June 17, 201718

TEAM Concept in Palliative Care
Assessment: Formal assessments for••••

Symptoms (ESAS, MSAS-C, CAPC rounding tool);
Spirituality (FICA, or “Are you a religious or spiritual person?”);Psychosocial (Distress Thermometer, others)
Goal Setting• The tools are all available in a checklist format:
http://www.asco.org/sites/new-www.asco.org/files/contentfiles/practice-and-guidelines/documents/2016-palliative-carechecklist.pdf

June 17, 2017

19

TEAM - Assessments
Does not matter which one youuse
But use one!
“Are you bothered by ____?”

June 17, 201720

Always do a religious/spiritual assessment – and getsome help.
Is religion or spirituality important to you?
The chaplain is part of our team. I am going to ask her to see you.

Generates referral to Pastoral Care
• 87% of patients want us to know their spiritual needs; 6% ofus ask. Balboni M, et al. J Clin Oncol. 2013 Feb 1;31(4):461-7• People who get spiritual care from chaplains use hospice
more, ICU less. (TS- Better care at EOL, at a cost we canafford.) Balboni TM, et al. JAMA Intern Med. 2013 Jun24;173(12):1109-17
June 17, 201721

Do the spiritual assessment, call the chaplain, and have a Goals ofCare/EOL discussion if appropriate – it changes care at the end of life.

82% chanceof Hospicewith End ofLifediscussion
and chaplain

And noone diedin theICU• People who have EOL discussion and get spiritual care from chaplains use hospice more,
ICU less. Balboni TM, et al. JAMA Intern Med. 2013 Jun 24;173(12):1109-17

June 17, 201722

TEAM Concept in Palliative Care
Assessment: Start with Communication Prompts

Inspired by Morris DA, Johnson KS, Ammarell N, Arnold RM, Tulsky JA, Steinhauser KE. What is your understanding ofyour illness? A communication tool to explore patients' perspectives of living with advanced illness. J Gen Intern Med.
2012 Nov;27(11):1460-6. doi: 10.1007/s11606-012-2109-2. Epub 2012 May 26.

June 17, 201723

Goals of Care embedded in the EMR
 INFO Understanding Goals AMDs CODE status SOME STRUCTURED SYMPTOM
ASSESSMENT (ESAS, MSAS-C,CAPC tool) Spiritual assessment• Opioids 101• Adjuvants 101• CPR discussion anddocumentation*• Goals of Care discussions “What do
you think will happen to you?”

Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a moresustainable model N Engl J Med. 2013 Mar 28;368(13):1173-5. doi: 10.1056/NEJMp1215620.
Epub 2013 Mar 6.

Specialty PC for the hardest cases• Opioid rotation• Gabapentin for cough, pruritis• Nebulized lidocaine for cough• Opioids for dyspnea (mimicendogenous opioids)• Nebulized fentanyl for dyspnea• Methadone• Assume opioid prescribing• Checking in CRISP or similar
database• Ketamine po and IV• Lidocaine infusions• Neuropathic pain prevention andtreatment• Single fraction RADIATION• Blocks, Intrathecal meds, spinal andperipheral nerve stimulation••

Help move “stuck” people to do AMDs
Help with legacy work

Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a more sustainable model N
Engl J Med. 2013 Mar 28;368(13):1173-5. doi: 10.1056/NEJMp1215620. Epub 2013 Mar 6.
Cheng MJ, King LM, Alesi ER, Smith TJ.Doing palliative care in the oncology office. J Oncol Pract. 2013
Mar;9(2):84-8. doi: 10.1200/JOP.2013.000885.

TEAM Concept in Palliative CareManagement:• by set protocols AND an interdisciplinary team (APNs, socialworkers, chaplains, doctors, pharmacists)• Those who have END OF LIFE discussions (goals ofcare, understanding of illness) are more likely to besatisfied, die at the place of their choosing, have lessdistressed relatives, etc.
• But we MUST start the conversations.
–––

Stein RA, Sharpe L, Bell ML, Boyle FM, Dunn SM, Clarke SJ. Randomized controlled trial of a structured
intervention to facilitate end-of-life decision making in patients with advanced cancer. J Clin Oncol. 2013 Sep
20;31(27):3403-10. doi: 10.1200/JCO.2011.40.8872. Epub 2013 Jul 29.
Mack JW, Walling A, Dy S, Antonio AL, Adams, Keating N, Tisnado D. Patient beliefs that chemotherapy
may be curative and care received at the end of life among patients with metastatic lung and colorectal
cancer. Cancer. 2015 Jun 1;121(11):1891-7. doi: 10.1002/cncr.29250. Epub 2015 Feb 11.
Kumar P, Temel JS. End-of-life care discussions in patients with advanced cancer. J Clin Oncol. 2013 Sep
20;31(27):3315-9. doi: 10.1200/JCO.2013.49.6562. Epub 2013 Jul 29.

June 17, 201726

TEAM Concept in Palliative CareManagement:• When the patient has progressive disease, or ECOG
performance status change, bring up the prognosis again.
“Would you like to discuss what this means?”• Prognostic Disclosure discussions decreased patient’s overoptimistic life expectancy by 17 months.
–•Enzinger AC, Zhang B, Schrag D, Prigerson HG. Outcomes of Prognostic Disclosure:
Associations With Prognostic Understanding, Distress, and Relationship With Physician
Among Patients With Advanced Cancer. J Clin Oncol. 2015 Nov 10;33(32):3809-16. doi:
10.1200/JCO.2015.61.9239. Epub 2015 Oct 5.

If palliative care sees the patient as an inpatient, the 30-dayreadmission rate is cut from 15% to 10%. If during that consultation,
we have the “goals of care” discussion the 30-day readmission raterisk is cut to 5%.
–O'Connor NR, Moyer ME, Behta M, Casarett DJ. The Impact of Inpatient Palliative Care
Consultations on 30-Day Hospital Readmissions J Palliat Med. 2015 Nov;18(11):956-61. doi:
10.1089/jpm.2015.0138. Epub 2015 Aug 13.

June 17, 201727

Divisional Data
Wang X, et al. J Oncol Pract. 2017 May;13(5):e496-e504. doi:
10.1200/JOP.2016.018093.

These folks mayneed sometraining* andencouragement* The surprise question: “Would you be surprised if this person died in the next 6
JuneIf17,2017
months?
not,
set up a ‘Hospice Information Visit’ to introduce a planned transition.”28

Conclusions
1.

ASCO now recommends concurrent palliative care by aninterdisciplinary team within 8 weeks of diagnosis.
Oncologists may be able to provide some of this careourselves.
Expect2.
3.
––––

An hour a month per patient
Difficult conversations
Hospice information visit to ensure smooth transition for “if and when”
neededWhenever the scan is worse, ask “Would you like to discuss what thismeans?”

June 17, 201729