Okay, so I'm a palliative care specialist in addition to being a gynecologic oncologist. So this is a very basic introductory discussion about palliative care, supportive care for women with cancer. And obviously it would apply to other fields, just not cancer, women's cancer. This is true for just about everybody. The other thing is humor is really important. So I use a fair number of cartoons through this. Hopefully none of them are offensive to anybody. I've tried hard not to offend anybody, but if for chance there is something you find offensive, just tell me at the end and I'll modify it. So Susan, can we go to the next? So palliative care, this now is actually getting to be an old article taken from the Washington Post. And it was talking about palliative care. And the point out of this was at least a decade ago, very few people actually had heard of palliative care, maybe a quarter of the people. And most people who were asked about palliative care confused it with hospice care. And I'll talk a little while about the differences between the two. But at least in about a decade ago, about half the hospitals, maybe a little bit more, had palliative care programs. I suspect, I haven't seen any new data, but I suspect that now it's almost every large hospital, certainly in the US, has some form of a palliative care program. We here at Stony Brook, we have a formal palliative care service. It's run by board certified specialists in palliative care. And they provide a variety of services on an inpatient basis. And then we collaborate with the outpatient palliative care services. It is cost effective, and it has been shown over and over again. The problem is that it's cost effective on the long run, and it is not cost effective up front. And so hospitals sometimes need to be nudged to understand that it's beneficial in a global setting, it is still costly on an individual point to point setting. And then the most important point is that it is very effective at improving the quality of life for our patients. Next slide, Susan. So the definition, if you look up in an English dictionary, the definition of palliative is when used as an adjective, it's to relieve pain or alleviate a problem. You can insert suffering in there and without dealing with the underlying cause. And that's what most people are familiar with. But it also can be used as a noun. So a palliative is a remedy or a medicine that improves somebody's feeling, again, kind of alleviate suffering. So in that example, aspirin can be considered a palliative. Next slide. So traditionally, palliative care was viewed this way. There was a long period of active treatment, surgery, chemotherapy, radiation therapy, hormonal therapy, whatever one felt was necessary to actively treat the patient. Then there came a period of time where it was clear that their cancer was no longer curable and the patient was starting to progress towards death. And generally at that point, some form of palliative care was implemented. Next slide. So this is the traditional view. This was taken from an article not so long ago. Recurrent cancer of the ovary is seldom curable. The bolding and underlying is mine. Second, third, or even fourth-line chemotherapies offered administered in a palliative fashion, meaning to diminish symptoms and an attempt to prolong life. Next slide. So here's an example. This is a made-up patient, but all of us who do gynecology have had many patients almost exactly like this. In the traditional view, Ms. Jones has stage IIIc epithelial cancer of the ovary. She undergoes standard cytoreductive surgery followed by taxyl carboplatinum-based chemotherapy. Some months, however many months, she has a recurrence and is then treated with topotecan. Two or three months after that, her cancer progresses and she's treated with Doxil. Some months, usually two after that, her cancer progresses yet again and she's treated with gemcitabine and cisplatinum. The drugs here don't really matter. We all have our own favorite sequence. The point is that she goes from recurrence to progression to progression without any break or any reconsideration. She then presents, as often is the case, with a small bowel obstruction. She undergoes surgery that's unsuccessful at relieving her obstruction. She has pain, progressive weakness, altered mental status due to electrolyte imbalances. Then nine days before she dies, she's finally admitted to hospice. And overall, she lives about 43 months from her diagnosis. Again, we've all had patients probably exactly like this. Next slide. So in the contemporary view of palliative care, this is the approach we take now. So at the beginning, when somebody presents with their first diagnosis, the predominance of their treatment is curative or life belonging. At least that's the underlying intent. But along with that and in parallel and not exclusive is the implementation of palliative and comfort intent treatment. So for example, one can argue that we've been doing this for a long time. So a patient has surgery. You give her pain medication to alleviate the pain from her surgery. That's palliative. That's relieving or alleviating her suffering from an underlying problem. So as she goes through her treatment for her cancer, we focus heavily on trying to alleviate some of the symptoms that are due to either her cancer or sometimes related to the treatment that we're providing. So over time, as the curative or life belonging intent treatment alters, potentially the palliative care and comfort intent treatment alters concomitantly with that. As one goes down, the other increases. And then ultimately, if the patient dies, then there's a bereavement process that in the old days, we just walked away from. Nowadays, the palliative care service works very closely with the family, with friends, with those who are left behind to attempt to ease their suffering as they go through the bereavement process. Next slide. So CMS in the United States is the governmental agency that oversees Medicare and Medicaid. So they pay for the majority of healthcare for the elderly, which is most of our patients. This was their definition of palliative care when they were working on approving funding for palliative care in the United States. And it means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Again, the underline in the bold is mine. So palliative care occurs throughout the continuum of illness. And to summarize the rest of it, we focus on all of the aspects that one potentially needs to address in order to maintain the patient's dignity, autonomy, and overall quality of life. Next slide, Susan. So if we go back to our hypothetical patient, Ms. Jones, and treat her now, as opposed to a decade ago, again, she has stage three C cancer of the ovary. She undergoes standard cytoreductive surgery followed by taxyl carboplatinum-based chemotherapy. But this time, before she's discharged from the hospital, she's seen by a palliative care team. Here at our institution, as is true in many places, the palliative care team is led by a physician, but includes clinical pharmacists, social worker, a nutritionist, a spiritual guide of some sort, whether it's a chaplain, imam, a rabbi. We have access here, fortunately, because it's New York, we have access to somebody for everybody. We even have a Wiccan witch who will come and work with our patients if need be. And again, here, because it's the United States and you can't get away from it, we have an attorney on the palliative care team as well. So the patient goes through chemotherapy, unfortunately has a recurrence. Again, she's treated with Topatecan. Again, the actual drug doesn't matter. But this time, she's referred to the palliative care team before she starts chemotherapy to address potential side effects associated with chemotherapy. She progresses, unfortunately, and is treated with Doxil. Palliative care team is actively involved during this time. She progresses again, and this time, instead of going on to fourth-line chemotherapy, chemotherapy is stopped, and much of the management is transitioned to the palliative care team to focus on alleviation of suffering. She develops her small bowel obstruction, but instead of going to surgery, she has a palliative gastrostomy tube placed for comfort measures. Hospice care is instituted. And she is well-controlled with regards to pain and other symptoms at home. And she dies at home, surrounded by family and friends, five weeks later. And she survives 49 months as opposed to 43 months, and has a much more dignified, painless death than her theoretical colleague a decade before. So next slide. So I mentioned earlier about the differences between palliative care and hospice care. Palliative care is the overarching umbrella. It's appropriate at any time during management of a serious illness, and it should be provided concomitantly with, and in addition to, life-prolonging therapy. Here, there's no prognostic requirements to be able to say patient has a six-month life expectancy. By the way, six months in the U.S. for prognosis requirements for hospice was a negotiated agreement at CMS when they were deciding whether or not to pay for palliative care and hospice care. So there's no magic about six months. The longest patient that I've had in hospice was in for almost three years. At the end of six months, we just have to recertify, and then it goes on a three-month rolling enrollment. And so every three months, I recertified her. I kept telling her she didn't need hospice at that point, and she kept telling me that she really appreciated the care and she wanted it. So with palliative care, there's no prognostic requirements, and you don't have to choose between one or the other. Hospice care is palliative care provided at the end of life. Here, it's within the last six months by CMS definition, but it could be longer than that. At least for us, it mainly is a billing issue, and it can be as long as necessary. So next slide. So this is the evolving model of palliative care under the umbrella of psychosocial and spiritual support, and we provide disease-focused care concomitantly with, in conjunction with, and simultaneously with comfort-focused care. And as I mentioned, we all do this anyway without thinking about it very much, but now it becomes a more thoughtful, more directed process. If the patient ultimately passes away, then there's follow-up with the patient's family and even friends here to assist them with the bereavement process. Next slide. So as I mentioned here, we're fortunate. We have a palliative care team. It's a team of experts. They're all volunteers. This is what they choose to do. So they're very dedicated and committed to their process. It's physicians, nurses, nurse practitioners, physicians' assistants, social workers, chaplains just as a shorthand for a spiritual care provider. We have a clinical pharmacist, we have nutritionists, and then we bring in others as necessary, including the attorneys, and so on and so forth. They provide a variety of care activities for the patient, all of which is guided by the patient's needs. Next slide. So these are the goals, and I don't have to read them to you. You can see them. Functionally, the goal is to relieve suffering. That's the easiest way to define this. So we treat pain however one defines pain, whether it's physical pain, emotional pain, spiritual pain, we try to treat pain. The goal is to allow the patient to live with dignity and as actively and normally for as long as possible and then when the patient succumbs, then we provide a support system to assist the family because it's well-recognized. Patients don't die alone. Their death impacts many, many individuals, not just those immediately caring for them. Next slide. So some of these I've already discussed. I am with Palliative Care. So chemotherapy-induced symptoms, we all know them. Nausea, vomiting, fatigue, mouth sores are just some of the examples. There are issues with transportation, both for the patient and maybe for family members, and then spirituality is very important. And so each one of our specialists on the Palliative Care service provide services to those patients within their area of expertise. And then because it's a team, the team is much greater than individuals by themselves. Next slide. So why do it? I talked about this at the very beginning. It's beneficial. Patients feel better. The families feel better. And however one wants to define a quote-unquote good death, the studies, and there's an increasing body of literature, scientific literature with Palliative Care. And the studies have shown that whatever or however one defines a good death, one is far more likely to achieve a good death under the care of a Palliative Care service than without Palliative Care. So it is beneficial. It does improve survival. There was a landmark study done not far from here looking at lung cancer patients where the treatment was exactly the same for the two groups. One was assigned to usual care. The other was assigned to a Palliative Care service. Otherwise the treatment was exactly the same. And lo and behold, patients with Palliative Care service survived longer and at lower cost, which these days is a benefit to everybody. Next slide. So that's my story. I'm sticking to it. I think we have a little bit of time.

palliative care

women with cancer

humor in palliative care

integrating palliative care

CMS definition of palliative care