Thomas J. Smith, MD: An Overview of Palliative Care from ASCO 2011
Thomas J. Smith, MD, FACP is a Massey Endowed Professor of Palliative Care Research & Medicine from Virgina Commonwealth University-Massey Cancer Center. Dr. Smith provides a great overview on palliative care for cancer patients in the United States at ASCO 2011.
The Group Room at the 2011 American Association For Cancer Research Annual Meeting was made possible, in part, by:
VIDEO TRANSCRIPT
Selma R. Schimmel, Founder & CEO, Vital Options International:
This is Selma Schimmel at the 2011 ASCO meeting in Chicago, and we’ve been speaking to many physicians about some of the innovative therapies and breakthroughs and data that’s being presented at this meeting. And we’re going to expand our discussion now into an area of oncology care that sometimes we don’t talk about, and we certainly don’t talk about enough. And we’re going to introduce you to that subject now with Dr. Thomas Smith: Professor of Medicine and Palliative Care Research, the Director of the Thomas Palliative Care Unit at Virginia Commonwealth University, Massey Cancer Center, Richmond, Virginia. Hello, Dr. Smith.
Thomas J. Smith, MD, Med. Director, Thomas Palliative Care Unit, VCU Massey Cancer Center:
Hello. Thank you for inviting me to be here.
Selma R. Schimmel:
What we want to explore with you is, what is palliative care, how do we demystify it, how do we make it part of the dialogue that should go on as a natural part of the cancer discussion.
Thomas J. Smith:
There’s nothing mysterious about palliative care. Good doctors and good nurses have been doing it forever. Palliative care, as we define it, focuses on medically appropriate goal setting, what can and cannot be done against the cancer realistically, absolutely open and honest communication with patients and families, taking the time to do that, writing down what the options are, the pros and cons, and paying meticulous attention to symptom assessment and symptom relief. And in fact, palliative care is done right alongside bone marrow transplant, right alongside liver transplant; it’s not just about end of life care anymore. Palliative care arose from the hospice movement, which focuses on demedicalizing death and letting people be at home, where they want, rather than being in the ICU hooked up to machines away from everything that’s familiar to them. And it takes many of those same principles about open and honest communication, and what’s an appropriate medical goal, and symptom assessment and relief, and translates them right into the hospital or into the clinic.
Selma R. Schimmel:
Is the root of palliative care and hospice care really from the UK? Is it something that we brought here to the United States many years ago? But did it originate in England?
Thomas J. Smith:
Hospice arose in the UK as a way of demystifying death and getting people out of the hospital, where people really don’t want to be, and putting the emphasis back on spiritual care and family care and helping people adapt to bereavement, which again, most oncologists get no training in whatsoever. And then palliative care actually arose in Montreal because Balfour Mount, who was a thoracic oncology surgeon, found that he could speak about hospice with his English patients but he couldn’t speak about hospice with his French-Canadian patients because hospice was associated with the middle ages, it was a place you went to die and were abandoned; so it wasn’t a very good word, it had a horrible connotation in their culture. So he came up with the word palliate, which is from the Latin pallium, which is to throw a cloak over to cover up symptoms. And it’s grown from throwing a cloak over symptoms to being part and parcel of usual medical care. I think the data are reasonably clear, when palliative care is given alongside usual oncology care that, at least in one big, well done study people lived longer, 2.7-months longer, and in the other 7 or 8 good, randomized studies there’s not a hint of people dying sooner, there are several hints of people living longer. But people who have exposure to hospice and palliative care earlier in their disease process are less likely to be depressed, they don’t give up hope, their care givers fair better, the patient themself is far less likely to die in the hospital, far less likely to die in the ICU, far less likely to die on a ventilator and much more likely to be at home with family and friends and pets… and resolve spiritual issues and family issues and financial issues and do what my friend Harvey Chochinov calls, the life review. What is it about your life that you want to write down, or DVD in today’s terms, what is it that you want to DVD for your kids and grandkids about you and what you’ve learned? If nobody brings that up, if nobody brings up the D-word, which is not docetaxel or doxorubicin, if nobody brings up the death word then a lot of that doesn’t get planned for. And our experience has been that most people, most patients and families are thankful for bringing it up.
Palliative care is happy to be involved when people have curable illnesses. One thing I take away from this meeting is that we’re still making progress, albeit somewhat slow and not as quick as any of us would like but even with all the new drugs there’s still going to be death from heart disease, death from cancer, death from strokes and it’s much better to plan for all those things.
The good news is, at least in my practice in the US, that 95% of patients will say ‘tell me everything, Dr.” That’s been studied in England, and Australia, Canada, Europe… it’s pretty much the same, could vary from culture to culture. And I work in some of the former Soviet Union and I work in East Africa and it varies from culture to culture, but here in the US, 95% of patients will say, “tell me everything, Dr.”
Selma R. Schimmel:
Dr. Smith, do you find that patients that have a strong spiritual life or are faith-based have an easier time confronting death?
Thomas J. Smith:
I wish there was one group of people who had an easy time confronting the end of their lives and leaving people behind and not finishing the tasks that they’d set out to do, but they don’t. And people who have a strong faith may be the ones who absolutely insist on dying in the ICU and dying on a ventilator. And I often hear from my patients, “well, God has a plan for me and as long as you can keep my heart beating there might be a chance that I could be saved.” And I’ll also hear from people who really don’t have any religious or spiritual interest, “I’m comfortable, I’ve made peace, I’ve made peace with me, I’ve made peace with my family, I’ve made spiritual peace, such as it is, that’s not important to me.” It all varies by person to person. What we have found, and I think what the studies show, is that people who get their religious help from hospital based chaplains often fair better than those that are getting their religious help from people of cloth in the community. We’ve worked with ministers, rabbis, imams, almost everybody and I can tell you that a lot of religious leaders are very uncomfortable with death, too. And I’m not suggesting that physicians should take the role of spiritual leaders, I’m just saying that for many people it’s a critically important part of their life and you can ask the question, “is faith important to you? Are there spiritual things that you want to do that you haven’t done? Are there parts of you that are looking for peace?” And it’s not an out of the blue question because you’re asking it about, “are there family issues that should be settled? Are there spiritual issues?” Just working it in as number 2 rather than the prime 1… “Are there financial issues that should be settled?” And my patients don’t expect me to settle these issues for them, but it really helps for them to have a check list of how to prepare.
Selma R. Schimmel:
You have a presentation, or there has been a presentation of palliative care at ASCO at this meeting?
Thomas J. Smith:
We’re specifically giving a program, Jeff Peppercorn and I, about how oncologists deal with this, so the who, what, where, when and why standard cancer treatment fails. And I’d love to rename that as, standard cancer treatment includes attempts at cure, attempts at palliation and taking care of the people when cancer treatment like chemotherapy, radiation therapy hasn’t worked to everyone’s satisfaction, but that’s too big to put on a slide. It’s not the patient who fails therapy, it’s the therapy that fails the patient, and blaming the patient doesn’t do any good. That’s the time when many oncologists, and I’ll say that sometimes me, find it really difficult to continue contact with the family and patient. You are so invested in their care, so invested and you feel so personally responsible for what happens to them that when things go poorly, even though you know it’s not your fault, you often feel, deep inside, that you are somehow responsible. And for a lot of doctors it’s hard to get over that hurdle and call the patient on the phone and ask how they’re doing. One simple trick that I’ve evolved in my own practice when I am stopping chemotherapy on somebody, but hopefully not stopping their care, but one trick that I’ve learned is to put a 15-minute appointment in at ten o’clock 2 weeks from now, 4 weeks from now, and 6 weeks from now. So that way, the person isn’t coming in for their chemotherapy, but it’s a reminder to me to pick up the phone and say, “hi, this is Tom Smith and I’m here with Judy Grappin, the nurse, at the cancer center and we’re just wondering how things were.”
Selma R. Schimmel:
That phone call, I can only imagine what that would mean to me.
Thomas J. Smith:
It’s a big deal. It’s a big deal for patients and families that they haven’t been abandoned because some… the way hospice care is set up in the US, it can really feel like abandonment because you can’t get concurrent hospice care and regular cancer care. There are some models that are working on that but right now, for most people, you can’t get that. So you go from the doctors and nurses and scheduling secretary who know everything about you, they’ve taken care of you for 7 years while you battled metastatic breast cancer, and then suddenly you are cut off from them and sent home with a different team and told to call that doctor and that nurse rather than the team that’s been taking care of you. I used to think I would dread making those phone calls and sometimes I still do, particularly if I haven’t heard from someone and I don’t know how they’re doing. But I often find that’s the most rewarding part of my day. That’s why most of us go into the helping professions because we want to be helpers.
Selma R. Schimmel:
I really want to thank you for enhancing here at ASCO, while we’re talking about all the innovative therapies, that we took some time out to really pay attention for helping those people that may not get to benefit from the new therapies but that can benefit from the advances being made in palliative care, and supportive care, and pain management, and matters of the heart and spirit.
Thomas J. Smith:
What you said really stimulated me to think about the science of communication because as you mentioned, we’re here at ASCO and there will be at least 100 new and exciting drugs and at least 500 new and exciting leads to treat cancer in novel ways, and yet that hasn’t trickled down to better survival for most cancers. We have figured out a whole science of communication and it’s really pretty simple: it’s asking the patient, “what do you know about your disease and what do you want to know about your disease and then, if they give you a leave, as 95% of US patients do, then exploring with them what’s going to happen with them, what can be done about it, what are the options, what are the side effects, what are the alternative treatments, reassuring them that you’ll be there when they get sick, reassuring them that you’ll treat their pain… And we know from well-designed scientific studies that that’s what people want if they can’t be cured. Frankly, that’s what people want if they can be cured, too; they want a healthcare team that is taking care of them as a person. But it’s especially important when people have a very short period of time to live.
Selma R. Schimmel:
Thank you, Dr. Thomas Smith: Professor of Medicine and Palliative Care Research, Director of the Thomas Palliative Care Unit, Virginia Commonwealth University, Massey Cancer Center, Richmond, Virginia.
Thomas J. Smith:
Thank you.
END OF VIDEO