Palliative Care

February 08, 2021

Information

February 7, 2021

Yale Cancer Center

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00:00Support for Yale Cancer Answers
00:02comes from AstraZeneca, dedicated
00:05to advancing options and providing
00:07hope for people living with cancer.
00:10More information at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:15your host doctor Anees Chagpar.
00:17Yale Cancer Answers features the
00:19latest information on cancer care by
00:21welcoming oncologists and specialists
00:23who are on the forefront of the
00:25battle to fight cancer. This week
00:27it's a conversation about palliative
00:29care with Doctor Laura Morrison.
00:31Doctor Morrison is an associate
00:33professor of medicine and geriatrics
00:35at the Yale School of Medicine,
00:36where Doctor Chagpar is a
00:40professor of surgical oncology.
00:42Laura,
00:42maybe we could start off by you
00:44telling us a little bit more about
00:47what exactly is palliative care.
00:49I get the sense that there are
00:52still some misperceptions about
00:53what the term really means.
00:57That's a common point.
01:00It's something that a lot of
01:03people still wonder about,
01:04so I'm really happy to
01:08give another sense of what it is.
01:11Palliative care is a medical
01:14subspecialty that focuses on quality
01:16of life for patients with serious
01:18illness of any type and their families.
01:24And we also focus on relieving suffering,
01:27so again, it's really about quality of life
01:30and relieving suffering as much as we can.
01:34This all takes place in the setting of
01:37an interdisciplinary professional team.
01:40And we really focus on physical symptoms.
01:44Coping and the stress that patients
01:47and families deal with around serious
01:49illness as well as trying to streamline
01:53and support good communication
01:55for patients and families so they
01:57get their questions answered
02:00as well as possible.
02:03But that sounds like a
02:07combination of pain
02:10medicine and psychology and
02:13it's a bit of social work mixed in.
02:18Tell us more about how that works and
02:21how that's different from people's
02:24usual doctors who also may be very
02:27interested in their quality of
02:30life?
02:33First of all, you know,
02:36we really hope that all health care
02:39professionals get some training in
02:41palliative care and that they provide
02:43what we would call primary palliative
02:46care or basic palliative care.
02:54These are primary skills in addressing basic
02:57pain management and providing an
03:02initial level of support
03:06around coping as well as some
03:11nice early communication
03:12support as well.
03:14Palliative care goes beyond that
03:16in terms of being very specialized
03:19and part of that is because we
03:22do have a team model of care.
03:25Not all institutions are
03:27equal in terms of how many
03:30resource supports they are
03:33able to put toward palliative care,
03:36but in our setting at Smilow and across Yale,
03:41we're really focused on having a robust team,
03:45and for us that includes
03:48social work, chaplaincy, nursing,
03:50both at an RN and an advanced
03:53practice nurse level.
03:55We also are very fortunate to have
03:58our team psychologist as well as
04:01a pharmacist and art therapist,
04:03so this is
04:06a very broad approach,
04:08and I think the special part
04:11about it is that you know,
04:13we acknowledge that
04:16pain and other symptoms are
04:19sort of a total phenomenon,
04:22meaning that people can have pain
04:26and anxiety and depression
04:29that is in different domains,
04:32meaning the spiritual,
04:34the physical,
04:35emotional and so are different
04:38team members can play really
04:41important roles in addressing symptoms
04:44across this kind of spectrum
04:47of suffering and really trying
04:49to again improve quality of life.
04:53As you think about suffering,
04:56particularly of our cancer patients,
04:58and many of them have symptoms.
05:01Whether it's symptoms related to
05:03treatment or whether it's symptoms
05:05related to the cancer itself,
05:07one can't help but think that the whole Covid
05:11crisis kind of exacerbated that suffering,
05:14especially when you put it into
05:16those domains of
05:19not just the physical suffering,
05:21but emotional suffering.
05:22Financial suffering.
05:24All of the things that covid kind
05:26of brought to the forefront.
05:29Did you find an uptick in the need
05:32for palliative care during the crisis?
05:36You know, I think you're absolutely right.
05:39Covid sent us something that we were
05:42really challenged by
05:46especially initially figuring out
05:48how we could best support both our
05:53colleagues and our patients and families.
05:57I think the need shifted.
06:00I think at first we weren't sure because
06:04of just the exposure issues and how
06:07to still be as helpful as possible,
06:10but I think what really happened
06:13was of course, as we all know,
06:16in the earlier surge there was such
06:20a concern about how sick people were,
06:23and of course unfortunately a lot of
06:27people were sick enough that they were
06:30in a place where they were not
06:33able to get better and were dying.
06:36And so for us in particular,
06:40we were really brought in for
06:43physical symptom management,
06:45especially around shortness of breath.
06:48Which is where we saw COVID
06:51hit us all very hard.
06:55So managing shortness of breath for
06:57people that were really suffering
07:00with that and trying to improve their
07:03day-to-day and in cases where people
07:06were sick enough that they were dying,
07:09we were really pulled in to
07:13be present with them as much as possible,
07:16but to really be involved in
07:19reaching out to their families.
07:22Trying to help our medical
07:25colleagues in the ICU's with
07:27spending extra time
07:30being available to families,
07:32especially and to really try to help there.
07:37Be some contact before someone died.
07:41So that was challenging
07:44in a different way for sure.
07:46And fortunately I think,
07:48now that we've gotten on top
07:51of Covid and learned so much,
07:53and people are really
07:56doing a lot better now,
07:58certainly not as many people are dying,
08:00but we still have those roles
08:03currently trying to
08:05still be present to have these
08:08harder discussions and prepare patients
08:10and families for what can happen.
08:13I actually just took care of a patient a
08:17week ago who was in her 90s and
08:21dealing with covid and in isolation.
08:25And was actually in a mode where
08:28the patient and daughter were
08:30accepting that she might not live
08:33through this covid episode for her,
08:37but in fact she has been able to
08:40be stable and come through that
08:43and actually come out of sort
08:46of a comfort focused time.
08:49And now we're focusing on how
08:52to think about supporting her
08:55the best we can for her to
08:57ultimately try to recover.
08:59So things are a little different now.
09:04I can imagine that,
09:06particularly during the covid crisis and
09:09and even now for patients in isolation,
09:12that comfort and that support
09:14and that communication,
09:16particularly with the family,
09:18must be really difficult.
09:19I mean, how do you
09:22do that when both
09:25the family wants to be with
09:27their loved ones who are facing
09:30a potentially terminal crisis,
09:33and patients themselves are suffering.
09:38And dealing with more than
09:41the usual because not only do they
09:44have their physical symptoms,
09:47but also the emotional isolation.
09:50How do you kind of bridge that and
09:54be with with the patient and
09:57be there for the family as well?
10:03It's such a privileged place to be.
10:07It's awfully difficult as well,
10:09but I think all of us on the team,
10:12whether it's one of our chaplains
10:15or one of our social workers, our nurses,
10:19I think all of us just try to bring
10:22110% of our presence
10:25to open up conversations to just try to give
10:30people the space and opportunity to express
10:35the deepest part of what's
10:37weighing on them and what they are
10:39most worried about and
10:42to acknowledge the sadness.
10:44The heaviness of the situation.
10:47Sometimes we're able to be
10:50in person with the patient.
10:53Occasionally, if someone really is
10:56seemingly in a place where they
11:00may be dying in the next hours,
11:04family may be able to visit
11:07briefly and we try to be present
11:10for those opportunities and to
11:13advocate for them when possible.
11:16We've also had the opportunity, obviously,
11:19to use technology and have families
11:23through FaceTime or through Zoom.
11:26and be able to
11:30see their loved one.
11:31Sometimes that person can respond
11:34and sometimes they can't.
11:39I think we try to always make it as
11:42personalized a situation as possible.
11:45Sometimes there's music that is meaningful
11:48to the patient or family members.
11:51Last week I had a patient who
11:56was dying and the family was able to
12:01let us know that that person really
12:04enjoyed jazz music and we were
12:07able to have that present and you
12:10know it seemed to be part of the
12:13quality that we could add to
12:16a sad situation for sure.
12:21I think earlier
12:25when we had more people who
12:28seemed to be facing death,
12:32we had a lot more technology
12:34and a lot more Zoom meetings,
12:37we would have occasionally a family who
12:40would get connected from around the world
12:43and Zoom together
12:46and sometimes they would stay on for
12:5012 or 24 hours with their loved one.
12:53Until they passed away.
12:59It's such a time to
13:01reflect on what matters to people
13:04and to try to help families be able
13:08to focus in on how much time we
13:10think we may have and
13:13what is possible to try to make
13:16things you know a little more
13:18meaningful to everybody.
13:20Yeah, it's so important,
13:22particularly at the end of life,
13:30and the suffering that the families go through
13:33doesn't end when their loved ones pass.
13:36In fact, sometimes is just starting
13:40to surge their own grief over the loss.
13:43What about palliative care for them?
13:46Does your role continue?
13:48Or how does that work?
13:51Yes, thank you for asking that
13:54question because it's so important
13:56to acknowledge
13:58that there's so much more
14:01to the journey for family members,
14:03especially, even after someone dies.
14:07So we're very fortunate within our
14:09Hospital system and
14:12Smilow that within our palliative
14:14care program we do have a bereavement
14:17service that's been really a critical part
14:20of what we do for a number of years now.
14:26We have two
14:29full time social workers,
14:32bereavement specialists, who work
14:35within our program and so when we
14:38do have a death on our service,
14:41we let our bereavement coordinators
14:44and specialists know about that particular
14:48family and then they are able to follow up.
14:52We have a number of really wonderful
14:56support group opportunities
14:58as well as the option for
15:01a referral for more formalized
15:03counseling or psychotherapy as well
15:06within our community,
15:08but I think the really important
15:11first step is just to make sure
15:14that we do have that follow through
15:17to be able to check on families
15:20and to really check in with them
15:23specifically weeks after to just
15:25see how they're coping.
15:28and to acknowledge
15:29all the normal parts of
15:32grief and the bereavement process.
15:35So that's absolutely critical to
15:38our community and something that I
15:41think is unique that we are able
15:43to provide in that regard.
15:47Great, we're going to take a
15:49short break for a medical minute.
15:51Please stay tuned to learn more
15:53information about palliative care
15:55with my guest Dr. Laura Morrison.
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16:49You're listening to Connecticut Public Radio.
16:53Welcome
16:53back to Yale Cancer Answers.
16:55This is doctor Anees Chagpar
16:58and I'm joined tonight by
17:00my guest doctor Laura Morrison.
17:02We're talking about palliative
17:04care and Laura,
17:05before the break we were talking a lot
17:08about how palliative care has a role
17:11in supporting patients and families,
17:13particularly at
17:15the time of of death and when
17:18patients are really suffering.
17:20But I think one of the misconceptions
17:22is this whole idea
17:24of palliative care versus
17:27Hospice versus death panels.
17:29Can you clarify where palliative
17:34care sits in this whole spectrum?
17:39Yes, absolutely.
17:40It's an important distinction,
17:42so palliative care again is for any patient
17:46with a serious illness in their family.
17:50That's a pretty broad group,
17:53but not everyone is referred to us so
17:59theoretically, anyone with a serious
18:02illness could request palliative
18:04care through their physician
18:09so palliative care can be involved
18:12for that extra attention
18:15to really improving quality of
18:18life and relieving suffering.
18:20That's part of many people's experience
18:23with serious illness and so with
18:26palliative care we
18:28coexist and Co manage our
18:31patients together with their
18:33specialists and physicians
18:35and primary care doctors.
18:38So for Smilow patients,
18:40that means that we're
18:42often Co managing with the
18:45oncologist or the hematologist.
18:47Hospice is a separate entity.
18:53Hospice is an opportunity
18:54for patients and families
18:56when a patient is coming to a time
18:59in their illness where their life is
19:03likely going to be limited in time.
19:06And so if someone has six months or
19:10less in their disease course, they
19:15may become eligible for Hospice and
19:19that happens in conjunction with
19:22making decisions usually to
19:25steer away from more therapies
19:28that would prolong life,
19:30and so it's a time when people
19:34are really focused on comfort and
19:37really having as their primary aim
19:40the quality of life and comfort,
19:44and potentially no longer pursuing
19:46curative or life prolonging therapy and so
19:50Hospice is a time when usually people
19:53are not as involved with their
19:56oncologist or hematologist anymore.
20:00And really palliative care
20:03can enter at any time and stay with
20:06people even if they are able to be cured.
20:09Or just have a long period of
20:12time in their illness
20:15course, and so I think that
20:18that's really important,
20:20because palliative care then does not
20:23mean that there is any sense that your
20:27life expectancy is somewhat limited.
20:30It simply means that you have some suffering,
20:35whether that is physical suffering,
20:37emotional suffering, spiritual suffering,
20:40or other needs in terms
20:45of communication or spiritual
20:47needs that could use the services of
20:52a dedicated interdisciplinary team?
20:54Is that right?
20:56That's absolutely right, yes.
21:01I think it often starts just
21:04with acknowledging what a change it
21:07is for people to be diagnosed with a
21:10serious illness and how stressful that is,
21:13and simply the stresses of being in
21:15the hospital and not being in your
21:18own realm of control in the same way.
21:21So it really starts at that very basic
21:24human level of just acknowledging that
21:26things are really changing for somebody.
21:29And as you pointed out, we do have that.
21:35And it may be that one member of
21:39our team is a little more relevant
21:42at one time or another,
21:44but we do have the full team to draw upon.
21:49So for instance, we have some patients,
21:52many patients in active treatment,
21:54and sometimes our real goal is just to
21:57get them through their active treatment
22:00in the best supported way possible.
22:03And that may mean that they're
22:05coming to an art therapy group.
22:08You know, while they're getting
22:11treatment for their breast cancer
22:13or their acute myeloid leukemia.
22:15Maybe at a later time they're
22:18coming into our clinic when they
22:21come in to see their hematologist,
22:23because we're helping them with
22:25pain or their fatigue.
22:27So we do have an inpatient,
22:29and an outpatient presence as well.
22:33I think that that's so important,
22:37particularly now during covid when
22:39you know the real thrust was to try
22:43to manage patients in an outpatient
22:45setting as much as possible.
22:47So for patients who are not in hospital,
22:51who may be at home,
22:55tell us more about how the outpatient
22:58palliative care services work.
23:00It seemed from our earlier
23:03discussion that the inpatient
23:05service was
23:08this multidisciplinary service
23:10integrated with the managing team,
23:12the oncologist, and together
23:14managing patients in the hospital.
23:17But for patients who are at home, how do you do that?
23:24Is tha by virtual visits.
23:28How does that really manifest?
23:32We have a really vibrant palliative
23:36care clinic that is located in New
23:40Haven within Smilow, so people come
23:44into the 4th or 8th floor usually.
23:49And then we also have one of our
23:52colleagues see patients as well
23:54at a number of the care centers
23:57around New Haven in North
24:01Haven and Guilford and Trumbull.
24:04Torrington, so there's
24:06a fairly good access to our services.
24:09As you're pointing out,
24:10the Covid situation has altered our
24:13practice patterns there as well,
24:15and we've come
24:17in and out of virtual
24:20and in person visits a couple of
24:22different times with the surges.
24:25But you know, eventually,
24:26obviously we hope to be
24:28back to mostly in person,
24:30but I think we all acknowledge
24:33that virtual visits are going to
24:35carry forward with us.
24:38At the moment,
24:40the majority of our clinic
24:42visits are virtual at this time,
24:44but you know you schedule an
24:48appointment with us just like
24:50you do with any other clinic
24:53if they are in person,
24:55then we often try to pair them
24:58up with someone's oncology or
25:00hematology visit so that people
25:03aren't making multiple trips,
25:05so we really do try to be wary
25:07of those extra burden
25:10issues for patients and families.
25:14So when you pull up caring
25:17and alleviation of suffering,
25:19whether that's pain or fatigue or
25:22nausea or any number of symptoms,
25:25physical, emotional or otherwise,
25:29some patients may be at
25:32home and suffering that way.
25:35Is there such a thing as
25:37home palliative care?
25:38Where people can
25:41deliver therapies at home?
25:44Yes, so it follows a model that is
25:49similar to home nursing services that
25:52we typically get through Medicare
25:56or private insurance so people can have
26:00what is called home palliative care.
26:04It's typically through the
26:07same kind of agency
26:09that regular home nurse would be set up,
26:14but these are specialized groups within that,
26:17so a number of our local organizations
26:20in the community around Connecticut
26:23have home palliative care services,
26:26and what that looks like for patients
26:31and families is really at the most a
26:35daily visit for an hour or two perhaps.
26:40They can also include physical and
26:42occupational therapy services within that,
26:44but the nursing component
26:46often isn't even everyday.
26:48It's sort of based on what the need of
26:51the patient is as far as the frequency.
26:55But these are typically nurses
26:58who may have had a prior
27:02opportunity to do some Hospice work.
27:06Or may have a particular interest or training
27:09in more on the palliative care side,
27:12and those skill sets are quite
27:15similar and they bring a more
27:18holistic approach to really assessing
27:20and trying to manage symptoms.
27:22The management part is still
27:25handled by a physician
27:27who is
27:29covering and supporting that Nurse.
27:36Offering that kind of nursing service
27:39would exist on its own for some patients
27:44that might then later transition into
27:47a Hospice type of approach as well.
27:51And so you mentioned insurance briefly,
27:54but expand on that a little bit more in
27:57terms of palliative care you had said,
28:00anyone who has a serious
28:02illness can request palliative care,
28:04but I'm sure many of our
28:06listeners might be thinking,
28:08it sounds like this is yet another cost
28:10with a specialized interdisciplinary team.
28:13Whether it's in the inpatient or
28:15the outpatient or the home setting,
28:17is that yet another medical bill
28:19that's going to add to the financial
28:22suffering that people have?
28:24Are these services generally
28:25covered by insurance?
28:28Thankfully, yes.
28:31Palliative care is considered
28:34a medical subspecialty,
28:36just as infectious disease,
28:39cardiology, neurology. So
28:42that part of the financial picture is
28:46really handled in a billing fashion
28:49just like any other subspecialty.
28:52Even similar to oncology or hematology.
28:55For the most part that would be
28:58covered by a private insurance
29:00as well as Medicare and Medicaid.
29:04Doctor Laura Morrison is an associate
29:06professor of medicine and geriatrics
29:08at the Yale School of Medicine.
29:10If you have questions,
29:12the address is canceranswers@yale.edu
29:13and past editions of the program
29:15are available in audio and written
29:17form at yalecancercenter.org.
29:19We hope you'll join us next week to
29:21learn more about the fight against
29:24cancer here on Connecticut Public Radio.