Advanced Cancer and End of Life

Advanced Cancer
and End of Life
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

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CME Provider Information

Goal
• To provide insight and guidance into the
challenges of advanced cancer in patients
nearing the end of life.
• A patient case study provides the foundation
to explore functional status and prognosis in
advanced cancer, with hospice as the active
plan of care. It identifies missed opportunities
that could have supported earlier goals-of-care
conversations, advance care planning, and a
timelier referral to hospice care.

• Identify the relationship between functional
status and prognosis in cancer
• Appreciate the benefits to patients of timely
end-of-life discussions
• Recognize the value of earlier hospice
referral for advanced cancer
Objectives

• 67-year-old male who presented to his PCP with
the following complaints over the past month:
– Cough
– Shortness of breath with exertion
– Mild to moderate left shoulder pain
Case Study of MK

• Hypertension
• Hyperlipidemia
• Ex-smoker, quit 5 years ago
• COPD, oxygen-dependent
Past Medical History

• Married
• One adult daughter
• One 9-month-old grandson
• Works at a T-shirt printing company
Social History

• Initial workup by PCP
– Chest X-ray reveals LUL haziness with
changes consistent with COPD
– CT chest confirms LUL mass, irregular
borders, and mediastinal lymphadenopathy
• Interventional pulmonology follow-up with
bronchoscopy with GPS-guided biopsy
• Pathology:
– Non-small-cell adenocarcinoma
(non-small-cell lung cancer, or NSCLC)
– Negative biomarkers
Diagnostic Workup

• Full staging PET scan reveals:
– Locally advanced NSCLC
• First-line chemotherapy with
Cisplatin and Etoposide with
concurrent radiation therapy
– Symptom management
• Norco 5/325 mg, one PO
every 4 hours as needed
for left shoulder pain
Oncology Plan of Care

• MK presents with:
– Nausea
– Vomiting
– Constipation,
no BM x 6 days
– Dehydration
– Anorexia
– Weight loss x
8 pounds
– Increasing left
shoulder pain
• Plan: direct admission
to hospital
S/P Chemo-XRT 1-Month Follow-Up

• Treatment:
– IV fluids
– Ondansetron 6 mg
every 6 hours
PRN nausea
– Miralax
– Enemas
• Discharged home
on day 4
Hospital Course

• Nausea: improves using
ondansetron
• Weakness: spends 12
hours/day in bed or recliner
• Not eating well but takes
PO fluids throughout
the day
• Norco 5/325 mg, takes
8 per day, with left
shoulder pain 7/10
• Eastern Cooperation Oncology
Group (ECOG) performance
status 3, chemotherapy held
• Follow-up appointment in
3 weeks for reassessment
Post-Hospital Oncology Visit

• ECOG 2
• Reports feeling better
• Decision to proceed with
CXT with 25% dose reduction
Oncology Follow-Up 3-Week Visit

• Vomiting
• Diarrhea
• Inability to tolerate PO
• Left shoulder pain
now 9/10
• New low thoracic back
pain x 3 days, unable
to move
• Dehydration
• T10 new pathologic
fracture on imaging
Post-CXT 1-Week ONC Visit

• Admitted to acute-care bed
• IV fluids
• Ondansetron IV
• Morphine IV
• High-flow O2
– Interventional radiology
able to perform kyphoplasty
with marked improvement
in thoracic back pain
• Re-imaging reveals:
– Progressive disease with
lymphangitic spread
– Increased lymphadenopathy
– Multiple lytic lesions to bone
(vertebral, ribs, left humerus)
– ECOG 4
Oncology Plan of Care

• Due to poor performance status
ECOG 4, no cancer-directed
treatment can be provided at
this time
• Recommend that MK “goes
home and gets stronger,”
follow-up with outpatient
to reassess
• Continue Norco PRN for pain
• Encourage nutritional supplements
• High-flow O2 contributed to a longer
length of stay, with need to wean
prior to discharge
• Discharged home with home
health and physical therapy (PT)
Oncology Care Conference

• RN visits once per week, assesses
vital signs and communicates
with oncology
• Pain 4/10 on Norco 5/325 mg,
8 tabs/day
• Anorexia
• Ongoing weight loss
• Constipated, using Miralax and
Dulcolax suppository PRN
• PT evaluation
– MK reluctant to participate
due to pain in left shoulder,
arm, and upper back
– After 3 PT visits, discharged
due to failure to progress
Home Health Trajectory

• Family contacts oncology office to convey
that MK cannot travel
– Oncology reports “there is nothing more
that can be done”
– Refers to hospice; MK dies within 4 days
of hospice admission
Family Concerns

• Oncology team recommends that MK and
his family meet with hospice due to poor
performance, ECOG 3, intolerance of
dose-reduced chemotherapy, and natural
trajectory of advanced lung cancer
– Team to gather information regarding
the services hospice can provide and
how hospice can help MK and his family
• Family agrees to meet with hospice liaison
for information, but wishes to pursue home
health with goals of restorative function
“What-If” Warning Shot: Post-Hospital Oncology Visit

ECOG
0: Fully active, able to carry on all pre-disease performance
without restriction.
1: Restricted in physically strenuous activity but ambulatory and
able to carry out work of a light or sedentary nature.
2: Ambulatory. Able to self-care. Unable to carry out work activities.
3: Limited self-care. Confined to bed/chair >50%.
4: Disabled. Unable to self-care. Totally confined to bed/chair.
5: Dead.
(ECOG 3 and 4 not generally recommended for chemotherapy; burden generally greater than benefits)
N=1,655
Prognostication Tools in Advanced Cancer:
The Role of Functional Status
Functional Status in Advanced Cancer Outcomes
Jang, R., et al. (2014). Simple Prognostic Model for Patients with Advanced Cancer Based on Performance Status. Journal of Oncology Practice, 10(5), e335-e341
Hospice-
Eligible

• Family notes that despite home
health and at-home PT, MK
is not improving
• One week later, they contact
MK’s oncologist and request
hospice be made available,
given they had met with a
hospice liaison earlier and
recall all the services hospice
can provide
• Hospice admits patient and the
following changes are made to
plan of care:
– HME ordered:
• Hospital bed to facilitate
transfers and hands-on care
• Over-bed table
• Commode to minimize exertion
to bathroom, conserve energy
• Home O2 (concentrator) for use
as needed for SOB, with portable
O2 tanks for use when going out
Family Recalls Warning Shot

• PT evaluation for home safety and education
on transfers
• Hospice physician visit to review the following:
– Goals-of-care discussion addresses advance
directives and healthcare proxy choices
– Given patient’s better understanding,
chooses to have a DNR code entered with
the understanding that he wishes to pursue
any issues that can be treated medically and
provide better QOL and function
– COPD as comorbidity also contributes
to function and prognosis
Hospice as an Active POC

End-of-life discussions:
• Give back control to patients
and offer hope
• ARE NOT associated with:
– Physiological distress
compared to those who
do not have end-of-life
discussions
• ARE associated with:
– 2x increased likelihood
of accepting a terminal
diagnosis
– 3x more likely to
complete DNR
– Almost 2x as likely to
complete a power of
attorney compared to
patients who do not have
McGill Psychological Subscale* Total Yes No P value
adjusted least square means (SE) Sample
“Depressed” 7.4 (2.9) 7.3 (0.2) 7.4 (0.2) 0.79
“Nervous or worried” 6.9 (3.2) 6.5 (0.3) 7.0 (0.3) 0.19
“Sad” 7.2 (3.0) 7.3 (0.2) 7.2 (0.2) 0.79
Acceptance, preferences and Total Yes No AOR (95% CI)
planning, N (%) Sample
Accepts illness is terminal 125 (37.7) 65 (52.9) 60 (28.7) 2.19 (1.40-3.43) ***
Against death in ICU 118 (35.5) 60 (48.8) 58 (27.8) 2.13 (1.35-3.37) **
Completed DNR order 134 (41.1) 75 (63.0) 59 (28.5) 3.12 (1.98-4.90) ***
Completed living will, durable 181 (55.2) 86 (71.7) 95 (46.1) 1.96 (1.25-3.07) **
power of attorney, or health care proxy
*Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable.
N=332 *P value<0.05 **P value<0.01 ***P value<0.001
End-of-Life Discussions Align Care
With Patients’ Wishes and Values
Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and
Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.

End-of-life discussions:
• Changed the care patients
received; care was
associated with a better
quality of life and death
• Reduced:
– ICU admissions by 65%
– Ventilator use by 74%
– Resuscitation by 84%
• Outpatient hospice care
for > 1 week increased 1.6x
compared to those without
Total Yes No AOR (95% CI)a
ICU admissions 31 (9.3) 5 (4.1) 26 (12.4) 0.35 (0.14-0.90)*
Ventilator use 25 (7.5) 2 (1.6) 23 (11.0) 0.26 (0.08-0.83)*
Resuscitation 15 (4.5) 1 (0.8) 14 (6.7) 0.16 (0.03-0.80)*
Out-patient hospice > 1 week 173 (52.3) 80 (65.6) 93 (44.5) 1.65 (1.04-2.63)*
*P value<0.05 **P value<0.01 ***P value<0.001
Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and
Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.
End-of-Life Discussions Align Treatments
With Patients’ Wishes and Values

Example of Hospice Care Model for Oncology Patients

• Medication review:
– Optimization of pain control, long-acting
and immediate-acting opioid
– Addition of gabapentin for nerve-related
pain from brachial plexopathy
– Bowel regimen to avoid further
constipation episodes
– Low-dose Remeron as appetite
stimulant and to aid with sleeping
– Titrated antihypertensive to lower dose,
given MK’s lower BP (not related)
– Continued anti-hyperlipidemia agents
(not related)
– Frank discussion about benefit/burden
of IV fluids. Decision to do time-limited
trial of IV fluids at home and reassess
Hospice as Active POC

• RN visits MK three times during
the first week
• Educates on medication management,
tracks the number of PRN doses of
immediate-release opioid required
per day. After discussion with hospice
physician, adjusts dose of the
long-acting opioid
• Increased respiratory distress noted
despite titrating oxygen; transitioned
to high-flow O2 by respiratory
therapist (RT)
• Notable improvement in the shooting,
shock-like pain from brachial plexopathy
with addition of gabapentin and titration
pursued slowly
• IV fluids time-limited trial (1 L) is effective;
patient’s nausea resolves, increased
energy and less fatigue are related to
decrease in immediate-release opioids
• Bowel movements regulate, feeling of
fullness resolves, improved PO intake
• SOB improves markedly with transition
to high-flow O2 and oral opioids
• Appetite and sleep improved with
Remeron nightly

• Social worker visits, reviews concerns
of MK and his family, identifies that
wife is struggling
– Counseling is arranged as follow-up
• Chaplain makes contact and is asked
to follow up during the second week,
as MK and his family feel overwhelmed
by amount of first-week activity
– Anticipatory guidance regarding
grief/grief support
– Appointment made for the
subsequent week
• Hospice aide services are offered
for support with personal care/hygiene
– Given MK is feeling better, family
defers at this time, but is aware
that aide services will be
available and important as
the patient’s condition changes

• 2 weeks after admission, MK
feels and functions better, ECOG 2,
pain controlled; wishes to speak with
oncologist at urging of daughter
visiting from out of state
• Makes appointment with oncologist and
has frank discussion about the critical
need to feel better and function
better to enjoy to the fullest the
time that remains
– Defers on further
cancer-directed therapies
• MK continues to receive hospice
services for 2 weeks before
demonstrating further decline.
During this time, with the help
of chaplain and social worker,
all funeral arrangements
are finalized
• MK is able to enjoy time with
grandson; hospice volunteers
help with memory making so his
grandson will have keepsakes

Temel, J., et al. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. New England Journal of Medicine, 363(8), 733-742.
Early Palliative Care Impacts Survival

• MK does well for additional 2
weeks at home, slowly declines,
becomes more lethargic, less
interactive. During repeat GOC
discussion with family, the
ultimate decision is to wean
MK’s high-flow O2 to nasal
cannula, supporting greater
benefit than burden
• MK dies peacefully surrounded
by family, with hospice nurse in
attendance at his death
• Bereavement services are provided
to family for 13 months post death
• Weekly updates are provided to
the oncology team throughout the
hospice course; they are notified
of MK’s death

The Benefits of Hospice for Patients Living With Cancer:
The Value Proposition
Utilization Non-Hospice Hospice Odds
Hospital Admission 65.1% 42.3% 1.5
ICU Admission 35.8% 14.8% 2.4
Invasive Procedure 51.0% 26.7% 1.9
Died Hospital/SNF
– Hospital
– SNF
74.1%
50.2%
23.9%
14.0%
3.4%
10.5%
5.3
14.6
2.3
• For Medicare fee-for-service
beneficiaries with poor-prognosis
cancer, those receiving hospice
care vs. not (control) had
significantly lower rates of:
– Hospitalization
– ICU admission
– Invasive procedures
at the end of life
– Total cost
• Patients not on hospice were
14x more likely to die in the
hospital compared to those
on hospice
Obermeyer, Z., et al. (2014). Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients with Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.

Hospice LOS, wks % Pop Non-Hospice Hospice Difference
1 38% $71,582 $66,779 $4,803
2 17% $70,987 $63,013 $7,848
3-4 15% $72,660 $59,595 $13,065
5-8 12% $74,890 $56,986 $17,903
9-26 12% $72,432 $60,326 $12,106
Total Costs Trajectories in Final Year of Life (Non-Hospice vs. Hospice) • For patients on hospice with an
average length of stay of 5-8
weeks, healthcare costs averaged:
– > $56,986 compared with
$74,890 for patients not
on hospice
– Cost savings = $17,903
Total Costs Trajectories in Final Year of Life
(Non-Hospice vs. Hospice)
The Benefits of Hospice for Patients Living With Cancer:
The Value Proposition (cont.)
Obermeyer, Z., et al. (2014). Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients with Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.

Substantial variation exists among providers in how hospice services are delivered
The Value of a Partnership With VITAS
Open Formulary for individualized care plans, including continuation of disease-directed medications to assist with pain, respiratory, GI, neurological, and constitutional symptoms.
VITAS nurse supervises medications and compliance to mitigate chances of readmission.
High-Acuity Care for patients requiring intensive symptom management and acute stabilization. Higher levels of care
support reduction in LOS and in-hospital mortality, free ICU bed availability, and reduce likelihood of readmissions.
Advanced Illness Specialists design and deliver customized, educational plans based on hospitals’ needs and goals, and
clinical resources and technologies to enhance prognostication of patients with advanced illness. Experienced clinicians assist
with goals-of-care conversations, medication reconciliation, and more.
Thought Leadership through strong academic and community partnerships focused on research, teaching, and patient care. VITAS sponsors fellowships
and clinical training for medical/nursing students, including CME offerings and grand rounds. Technology investments support improved prognostication.
Expanded Team ensures patients are receiving the highest level of symptom management and quality of life beyond hospice benefit requirements, including: respiratory therapist,
dietary support, PT/OT/speech, music, pet visits, massage, etc.
Complex Modalities for intensive symptom management using anti-tumor therapy, multimodal pain management, artificial fluid and
nutrition, oxygen, BiPAP, CPAP, tracheostomy, blood transfusion, TPN, IV fluids, paracentesis, nutritional counseling, proactive wound
management, etc.
24/7/365 Clinical Care Support provides round-the-clock access to clinicians for triage, assessment, and treatment guidance. Seamless care transitions
available at any time. Secure e-referral platform enables VITAS to receive, manage, and respond quickly to hospice referrals.

Outcome Hospice Nursing Home Home Health Hospital
Not enough help with pain, % 18.3 31.8 42.6 19.3
Not enough emotional support, % 34.6 56.2 70 51.7
Not always treated with respect, % 3.8 31.8 15.5 20.4
Not enough information on what
to expect while patient was dying, %
29.2 44.3 31.5 50
Quality care considered excellent, % 70.7 41.6 46.5 46.8
Results are presented only for the 1,380 decedents who had contact with a healthcare institution. Questions regarding quality were not asked of the 198 persons who died at home
without services.
Patient- and Family-Centered Reported Outcomes at the Last Place of Care
(cancer, heart disease, stroke, dementia)
Family members of patients receiving hospice services were more satisfied with overall quality of care:
70.7% rated care as “excellent” compared with less than 50% of those dying in an institutional setting
or with home health services.
The Benefits of Hospice: Patient and Family Experience of Care
Teno, J., et al. (2016). Family Perspectives on End-of-Life Care at the Last Place of Care. JAMA, 291(1), 88-93.

Advanced Cancer and
End of Life
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

References
Jang, R., et al. (2014). Simple Prognostic Model for Patients with Advanced Cancer Based on
Performance Status. Journal of Oncology Practice, 10(5), e335-e341.
Obermeyer, Z., et al. (2014). Association Between the Medicare Hospice Benefit and Health Care
Utilization and Costs for Patients with Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.
Temel, J., et al. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer.
New England Journal of Medicine, 363(8), 733-742.
Teno, J., et al. (2016). Family Perspectives on End-of-Life Care at the Last Place of Care. JAMA,
291(1), 88-93.
Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health,
Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.

This document contains confidential and proprietary business
information and may not be further distributed in any way, including but
not limited to email. This presentation is designed for clinicians and
healthcare professionals. While it cannot replace professional clinical
judgment, it is intended to guide clinicians and healthcare professionals
in establishing hospice eligibility for patients with advanced cancer.
It is provided for general educational and informational purposes only,
without a guarantee of the correctness or completeness of the
material presented.

Advanced Cancer and End of Life

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