Tuesday, March 22, 2011

Components of Early Outpatient Palliative Care Consultation for Patients with NSCLC

Vancouver 2011
We don't usually comment on stuff from the main palliative care journals, but the Journal of Palliative Medicine published a study that supplements the NEJM trial on early palliative care in metastatic non-small lung cancer.  (See our initial reactions to the NEJM study herehere, and here.)  The present study examines the content and length of time spent during the initial outpatient consultation that took place during the trial. 


In the study, palliative care notes from the EMR were reviewed to determine the amount of time spent (as estimated by the clinician who performed the consult) on each of the following tasks: management of symptoms, illness understanding, treatment decision-making, patient and family caregiver coping, and care planning and referrals.  The median time spent during initial consultations was 55 minutes with a range of 20-120 minutes. When looking at the components of consultation, a median of 20 minutes was spent on symptom management, 15 minutes was spent on coping, and 10 minutes spent on illness understanding with no recorded time spent on decision-making or planning and referrals.

Somewhat in keeping with the above results, a retrospective chart review revealed that 50% of clinicians documented a discussion of spiritual or religious practices (related to coping) but only 20% documented a discussion about surrogate decision-makers or code status.  Unless the clinician was merely noting what was already in the chart related to these topics, the latter result is inconsistent with the audit that suggested that no time was spent on decision-making or referrals.  This perhaps highlights a minor weakness of the method used for tracking time spent on the components, but we get the gist anyway. 

Regardless, in most patients, end of life decisions were not discussed at all during the initial consult.  The authors cite the fact that patients with metastatic NSCLC have a high symptom burden at time of diagnosis, thus prompting the need for this to be the main focus at first.  Furthermore, the intense focus on symptoms and coping engenders trust and helps build the rapport necessary to talk about end of life planning. Time spent discussing the patient's understanding of disease/trajectory lays the groundwork and also likely signals to the patient that further conversations about EOL decision-making may follow (and provides hints to the provider regarding goals of care). 

As I reflect on my own practice, I think the same type of thing often happens in the inpatient arena: during the first visit, focusing on immediate needs (both symptom and psychosocial), disease understanding, as well as trying to really get a good picture of the patient's "organic" support all take precedence over code status discussions, etc, in most cases.  (I often remind rotating learners of this: If we're consulted "to talk about code status", that doesn't mean that you delve right into talking about code status.)  Perhaps the inpatient consultation differs in that the hospitalized patient is already likely at a moment of crisis which allows for concrete discussion about wishes and goals in the context of that crisis.  In other words, discussion about the patient's understanding of their disease/acute illness (for instance, dealing with a malignant pleural effusion) seems like a more natural entree into goals exploration and preferences for life prolonging measures than a patient who is waiting around for their first cycle of carbo/taxol. 

Another major difference is the timing between visits in the clinic vs. the hospital.  In the hospital, you may not delve into details about the patient's goals or decision-making on the first day for various reasons (symptoms out of control, not the right setting, not enough trust established, etc, etc). You can risk-stratify how likely it will be that you will have the opportunity to return the next day to deepen the conversation.  In the clinic, I have experienced a very minor sense of anxiety that I haven't "done my job" if I haven't talked about decision-making/end of life planning, etc during an initial visit because there may be weeks in between the visits.  (And visions of the patient being admitted to the ICU pop into my head with the ICU doc saying to me, "Fettig, the family told us that the patient wouldn't have wanted all of this, and you saw this patient 3 weeks ago.  What were you doing?") So I find this study reassuring. 

More details are also provided about the structure of the randomized controlled trial intervention.  The providers consisted of 6 palliative care physicians and one nurse practitioner, although the NP provided 45% of initial consultations.  It's noted that visits were scheduled in conjunction with patients' oncology appointments when feasible.  I still have further questions about logistics (partially based on my own experience providing consultation in a general oncology clinic over the last year):
  • How often was it not feasible to see the patient on the same day as the oncologist?
  • What logistical dilemmas arise from doubling/tripling the time patients spend in clinic and how are those dilemmas managed? (Clinic room/space limitations, patients not wanting to wait around due to symptoms/other factors or needing to proceed to infusion, etc.)
  • Was time patients spent in the infusion clinic used at all by PC clinicians?
  • If the patient has a primary care clinician, how involved was that clinician, and how was care coordinated with him/her?
  • With so many palliative care providers involved, were there any issues with continuity of care between visits?  
Question for Pallimed readers:  It's been a full seven months since this important trial was released.  What impact have you seen and how have you used it to advance your services?

ResearchBlogging.orgJacobsen, J., Jackson, V., Dahlin, C., Greer, J., Perez-Cruz, P., Billings, J., Pirl, W., & Temel, J. (2011). Components of Early Outpatient Palliative Care Consultation in Patients with Metastatic Nonsmall Cell Lung Cancer Journal of Palliative Medicine DOI: 10.1089/jpm.2010.0382

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