Hematology and Medical Oncology Fellows

All Hematology-oncology post-graduate fellows serve on the palliative care inpatient consultation service for a one month mandatory rotation.

Diane Meier M.D., director of the Hertzberg Palliative Care Institute, in conjunction with R. Sean Morrison M.D., Research Director, and Jane Morris R.N., Clinical Director, drafted the following brief description of the palliative care rotation.

Palliative care provides treatment for seriously ill hospitalized and ambulatory patients and focuses on symptom management, enhancement of function, physical comfort, quality of life, psycho-social support and communicating with the patients and their families about the goals of medical care. Hematology-Oncology fellows will learn the basics of these approaches to patient care.

Goals of the Palliative Care Rotation

Communication with Colleagues

In-Patient Consultation Service

Most patients are seen in consultation; consults continue until the patient leaves the hospital or until palliative care services are no longer needed. Occasionally, most often for patients coming from ICU’s or surgical services, immediate transfer to the in-patient palliative care unit is appropriate.

In-Patient Palliative Care Unit

Located on 11E, a General Internal Medicine teaching unit, the in-patient facility has four beds for palliative care patients. Daily rounds conducted by clinical team members are accompanied by the internal medicine house staff responsible for the patient’s care. Patients eligible for transfer or direct admission to the Palliative Care Unit include: 1) those with difficult to control physical and/or emotional symptoms related to their advanced disease; 2) those patients (and their families) who need support in coming to terms with a progressive illness and establishing appropriate goals of care; 3) those transferred from critical care units for whom the goals of medical care are palliative. A patient does not have to be "terminally ill" to be appropriate for care on the in-patient palliative care unit.

Consult Forms

The palliative care service uses a consult form that prompts caregivers to note the patient’s symptom burden (11 symptoms scaled from none-0 to severe-3), proxy status, DNR status, Karnofsky performance scale, and the purpose(s) of the initial consultation (e.g. goals of care, pain, and other symptoms). These data are entered into a database by the palliative care attending or nurse coordinator, Jane Morris, on the day of the initial consultation (the original consult form stays in the medical record). The symptom assessment is completed for each patient every seventy-two hours. Daily, the database prints the symptom assessment scale only for those patients for whom it is due. Whenever possible, the patient provides the information for the symptom burden assessment. Otherwise, the family or team provides a surrogate assessment. The form requests the source of the information (e.g. the patient, family, or team).

Knowledge Assessment

A short, multiple-choice test in palliative medicine is administered at the beginning and end of the elective rotation to initially target areas of interest in palliative medicine, and finally to reveal whether educational objectives were accomplished. A compilation of relevant articles is distributed at the beginning of the rotation.

Oncologic Care

As the individual on service most skilled in oncologic care, Fellows are encouraged to offer suggestions related to the medical, surgical, and radiation options for palliation. For patients with a good performance status, effective chemotherapy may palliate symptoms related to disease burden. Pain related to osseous metastases may be effectively treated with radiation therapy. Surgical resection of a painful tumor purely for palliative purposes may be feasible. The use of a bisphosphonate for patients with lytic osseous metastases secondary to breast cancer, lung cancer, and multiple myeloma has been shown to decrease skeletal complications and effectively treat pain.

Sometimes disease and treatment-related metabolic abnormalities can be treated definitively. Cancer treatment related comorbidity includes hypothyroidism, hypopituitarism, adrenal insufficiency and anemia, all of which may be corrected by medical therapy and may substantially reduce symptoms of fatigue.

Other symptoms may be palliated by invasive maneuvers. Pleural effusions as a cause of dyspnea may be treated with drainage and sclerotherapy. Recurrent ascites may be drained by paracentesis, although palliation from this maneuver may be extremely transient. Confusion may be improved by intravenous hydration when its etiology is metabolic.

Psychological symptoms of depression may be compounded by feelings of abandonment when acurative therapy is withdrawn. Careful attention to and management of other symptoms may significantly improve the patient’s sense of well-being and dispel fears of abandonment. In addition, depression should be treated both by pharmacologic and talk therapy efforts.