Eduardo Bruera, M.D.
Professor and Chair
Palliative Care & Rehab Medicine
The University of Texas, M.D. Anderson Cancer Center
Dr. Baile: Hello, I'm Walter Baile, Director of the M.D. Anderson program on Interpersonal Communication and Relationship Enhancement. Today as part of our Roundtable Discussion Series where we interview experts in the field of medical communication and relationships with patients and families, we're pleased to visit with Dr. Eduardo Bruera. Dr. Bruera is Professor of Medicine and F.T. McGraw Chair of the Department of Palliative Care and Rehabilitation Medicine. He's a pioneer in the development of palliative care services and a leading scholar in symptom management, especially of patients at the end of life. So welcome. Eduardo.
Dr. Bruera: Thank you. I'm glad to be here.
Dr. Baile: Thank you for coming. I wonder if you could tell us a little bit about the palliative care and symptom management program here at M.D. Anderson and how it's organized and evolved so we can get an appreciation of the development and current status of something that's really what I consider to be state of the art.
Dr. Bruera: Thank you. Well yes we started in 1999: in July of 1999. Before then there was no palliative care program at Anderson and so we had the wonderful opportunity to start pretty well from scratch. And we organized the program around 3 main components: a tertiary palliative care unit that treats patients in very significant distress in the inpatient setting, two mobile teams and those two teams are visiting patients anywhere in the hospital where there is symptom distress or problems with transition to the community, and our outpatient center where patients are referred a little bit earlier in the trajectory of illness when their primary oncologist sees that there's a beginning of a change in the disease or that even if the disease is under reasonably good control there are distressing symptoms for the patient or distress for the family.
Dr. Baile: Oh thank you. You know, I wonder what you think are the most important factors that really brought palliative care forward in the last 10 years because I remember at one time that you really couldn't even talk about palliative care to patients or to doctors: that they were just afraid of telling patients that it meant that they were giving up on them.
Dr. Bruera: That's a very important point and I completely agree. There has been a massive change in the adoption of palliative care by primary oncologists, patients and families. I think there have been a number of components that have made this adoption possible. One of them has been a much better understanding that the palliative care programs are fully integrated with cancer care. They're not a stage that occurs after the completion of cancer treatment but something that occurs during cancer treatment so that the patients and families can take advantage of excellent symptom control, psycho social support during the trajectory of the disease. That has made oncologists much more comfortable with taking advantage of the palliative care services. The other I think development that has brought many patients to these treatments as compared to what happened before is that cancer treatments are now given much later in the trajectory of illness. Before with the traditional cyto-static chemotherapy, once the patients got to a certain point in their performance status, treatment was interrupted and patients went back to the community. With targeted therapies, patients stay on therapy much longer in the trajectory of illness so they develop a lot of symptoms and distress while at cancer centers. And so the need for palliative care programs has increased and the adoption of those programs has also increased very dramatically.
Dr. Baile: Very interesting. So have you had some success for example with colleagues for example in medical oncology in getting them -- in getting your services involved early on for example when they see a patient -- initially see a patient with advanced disease, are they more likely to call you now and get your help with symptom management to that patient and introduce them to palliative care and supportive care services at that time?
Dr. Bruera: Yes, it has been quite significant. And it's not universal. There are some physicians who like to stay delivering care by themselves, but the vast majority are taking advantage of working together with the palliative care team. The initial effort was focused on a small number of physicians who were quite supportive of the idea. Once we were able to deliver good care to the patients of those physicians that were very a very small number, then other colleagues started taking advantage of the service because they saw the level of satisfaction in the initial physicians we were working with. So it was mostly the good recommendation of these initial doctors who were referring to us what made the vast majority of the other physicians to take advantage of the palliative care program.
Dr. Baile: Interesting. Could you tell us a little bit about the inpatient palliative care service at M.D. Anderson? How that works? How many beds there are? How patients get referred to your service? How you integrate with hospice and home health and I think that -- because that's a rather large unit that you have no compared to other places in the country?
Dr. Bruera: Yes, and we recently did a survey showing that there are only 26 percent of comprehensive cancer centers who have designated beds for palliative care. So there is still a big problem with having these units open and operate. And we think it's a great opportunity. Patients in severe distress need a place where the nurses, the physicians, the counselors, the social workers, the chaplains, the rehabilitation staff work as one, single, cohesive team and in a physical plan where the patients and families feel comfortable and safe. So it is possible to implement sophisticated interdisciplinary care for these patients and families who are in severe distress. To us it's similar to an intensive care unit for the treatment of significant suffering and distress. The environment is conducive to a considerable relief of the distress and now we can work towards a fast, effective discharge. These units are highly financially reimbursable. They work well in general. And basically they are able to discharge more than 75 percent of the patients that made it. So it's not a tradition of more passive, slow paced, hospice environment. Its acute care, interdisciplinary care and approximately 39 percent of the patients we see in consultation at the mobile team, spend a little bit of time in the palliative care unit before discharge. So we believe it's not only a wonderful asset for the cancer center, for the patients and families, but it's also wonderful for the palliative care team because it provides us with a very sophisticated environment to stabilize the patients distress and rapidly proceed with a home discharge.
Dr. Baile: That's very interesting and I think important. And one of the aspects that I think you mentioned was the presence of a multi-disciplinary team. How does that work on the unit? In particular, do you see patients who really come from an environment where the goal may have been more curative and palliative -- the inpatient unit is sort of a transition both psychologically and physically for them or is there something different we need to understand about it?
Dr. Bruera: Yes, and that's a wonderful point. There are essentially we could say 2 groups of patients, the group of patients that are in the process of transitioning from the aggressive cancer treatment to the palliative - purely palliative - phase of the therapy and we are helping the patient and the family with a process of transition and with integration back to the community and then there is another group of patients who are having very significant symptom distress but there are plans to continue the cancer treatment. The breakdown of the 2 groups is about 70 percent of the patients are in the process of transition and 30 percent of the patients are going to maintain very active treatment. We find that both groups take great advantage of this setting and as you very well defined the inter-disciplinary team acts immediately. As soon as a patient comes into the unit, the different disciplines visit the patient and their family in all cases. So every patient is seen not only by physician and nurse, but also by the social worker, pastoral care, rehabilitation, dietitian and in cases where extra services are required we take a lot of advantage of help from psychologists, psychiatrists, pain specialists and other colleagues.
Dr. Baile: Well that's very interesting. So that even patients who are still on anti-cancer treatments and who are having problems with symptom management might come to your unit for a period of time to get stabilized? Is that correct?
Dr. Bruera: That's correct. That allows them to go back and continue and receiving treatments. We for example have developed an excellent relationship with our Phase I group and the majority of the patients they see for the first time are referred to us at the same time. So that we keep working in parallel both teams. And this is a good model we believe because this collaborative model of care allows patients to already know the palliative care team. When the moment for transition happens, it's a much easier process for both the primary team and for the palliative care team when there is already an existing connection between both teams and the patient and family.
Dr. Baile: So you find that there's a seamless continuity of services [inaudible]?
Dr. Bruera: Exactly, yes.
Dr. Baile: I wanted to ask you a little bit about in today's oncology environment, what do you see as the biggest obstacles to delivering high quality end of life care?
Dr. Bruera: Well I think one of the big challenges is that oncology has become very complex. There is a large number of new therapies. The imaging techniques have changed dramatically. The diagnostic opportunities are much more. When I was practicing oncology about 20 years ago, we had less than one-third of the agents available right now. Our diagnostic imaging was much more rudimentary. We didn't have you know very good blood markers. We didn't have a lot of targets for our interventions. So the work of the oncologist has become much more complex. The problems of the patient and family also are complex and patients are staying within the oncology team until much later in their trajectory of illness.
So there is much more of a need to work in a collective team effort to address not only the cancer diagnosis and treatment needs - what we might call the disease component - but also the very significant illness component that is the perspective that the patient and family bring to the hospital. And by dealing with the disease and the illness in a collective team effort, then we're able to achieve much better results. So I guess the complexity is dual. On one hand the patients develop more complex problems. On the other hand the treatments have become much more complex.
Dr. Baile: In fact, you know in discussing how medical oncology has become more complex and how it's begun to embrace palliative care which I've seen, I noticed that two years ago that the medical oncology fellows actually began rotating through palliative care. And I wondered if you could talk a little bit about their experiences and how you think that may have really broadened their education and helped them tune into what you have to offer?
Dr. Bruera: Yes, it has been a wonderful experience. By having the medical oncology fellows rotate for 1 month, we are able to work side by side and train them on a lot of the complex assessment and management issues in these patients and families. Those who go back to the community to practice find it as a very valuable experience. And those who will stay as junior faculty at M.D. Anderson are one of the main driving forces behind a large increase in the referrals to our team because by having been exposed to what palliative care can offer, then when they go to the different services as physicians - as junior faculty - they take advantage of referring patients to our team. We know that they rate our rotation as one of the highest experiences. So we're delighted to have them here. Regrettably other big oncology training programs in the nation do not have palliative care rotations. And ASCO has recently produced a position paper where they require that hopefully within the next 2 to 3 years the vast majority of oncology training programs will include this very valuable component.
Dr. Baile: That's fantastic and sounds very promising. And creating a cadre of junior faculty and junior clinicians who are not afraid to talk to patients about the importance of your services in managing their symptoms I think is a real boon to patient care. And I know now that from an educational standpoint palliative care is now a recognized formal fellowship and I wonder how that's going for you in terms of developing your training program because I know that's an important piece of our effort here at M.D. Anderson is our educational effort.
Dr. Bruera: Yes, and that has been another enormous advantage because it has allowed us to have fellows for 1 year training after they obtain their specialty. For 1 year they train in specific aspects of clinical delivery of palliative care. Some of them even take a second year as a research year. So it has allowed us to train highly sophisticated specialists in palliative care and the vast majority of our faculty were recruited from our training program. And that has been an enormous advantage. I have to express here my enormous gratefulness to you and your program for the work in mentoring them in sophisticated communication skills because that's something that our belief is that every oncologist, every palliative care doctor, in general every physician who sees seriously ill patients should take advantage as a way of decreasing - not only enhancing their professional work - but also decreasing their likelihood of professional burnout.
Dr. Baile: Well thanks. It's been a lot of fun working with the fellows and they're very eager to learn some of the -- how to deal with some of the more difficult communication challenges with patients. And speaking of unique educational programs, could you talk a minute about bus rounds because I went on bus rounds and I found it to be one of the most moving and important educational experiences I've ever had. So could you tell the audience what -- how you came about to think about that and how that's evolved.
Dr. Bruera: I started in Canada with much worse weather conditions and driving conditions. And then we moved into Houston. And the idea is that every month we spend one full morning, we leave around 8 o'clock from M.D. Anderson and we go into the homes where patients are receiving end of life care and occasionally also into the long term facilities where they're getting treatment. We ride the bus to the patient's home and we present the patient's problems in the bus. Then we all come out and visit the patient and the family in their own environment, ask the necessary questions and take a look at the conditions in which the patients are getting care at home. And then go back into the bus and discuss together the situation, the case, the patient's management and recommendations all the way to the next home so that at the end of the morning we have been able to see about 4 or 5 patients and families. And it provides a unique opportunity for hospital based physicians to be exposed to the reality of home for these patients. And it also provides the community based hospice physicians and nurses to get exposed to the way specialists based in hospitals think about clinical aspects. So this hybridization over the years has allowed us to create a little bit of a community of people working both in hospitals and in the community so that we all kind of try to improve the way we're delivering palliative care in the Houston area.
Dr. Baile: I was also very moved by some of the psychosocial issues that really evolve during the meeting with the patients and how the patients were really almost sort of pleased to see a group of people coming and visit them. Because I know in certain circumstances they can get very isolated, but to have folks come in and take an interest in how they're doing and interview them and ask them questions as part of the educational process, seemed that to be therapeutic in itself.
Dr. Bruera: That's a wonderful observation because we completely agree with that. We have seen over the years patients feel so much relief by the fact that there was this interest by their own hospital and hospice to bring these professionals. And of course while our goal primarily is to learn from their experience and to have an educational experience, there is also some recommendations that are made that might help their case. And also overall the way we deliver care in the community. So patients and families feel comfortable with the visit. And it's very important for our healthcare professionals because it helps them understand the reality of the illness experience for those patients and families. When we see them in the hospital setting - inpatient or outpatient - a lot of their background, their neighborhood, their furniture, their belief system is left behind. But when we are visitors in their homes, we suddenly get into their world and we're able to take in a lot of that experience in a much more profound way. And many times I encounter people many years after a bus round and they ask me about the -- what happened to very, very specific patients that they saw during that bus round because it obviously stayed with them in a very profound way. And so we enjoy the fact that these colleagues have internalized so deeply what they saw because that means that probably their learning experience has been very good.
Dr. Baile: I remember particularly one case that -- of a patient that we went to see in a very small, modest, lower middle class home. And the patient had a broken water pipe underneath the house. And I remember how disturbing it was to sort of think that there is someone at the end of life who can't get water: basic necessities. So it's extraordinarily sobering to really see this not only the physical struggles that people go through at the end of life but some of those psychosocial issues. And I think that one thing we ended up doing was putting some pressure on people to get that pipe fixed. And so I felt I was very happy when I found out that it was fixed because you know you form these attachments in a very short period of time...
Dr. Bruera: Yes.
Dr. Baile: ...to the plight of some of the patients.
Dr. Bruera: Yes. Wonderful.
Dr. Baile: Now I would be remiss if I didn't ask you about the research programs of your department and your faculty and what kind of things you're doing now and have done recently that would be of' interest of people to hear about in terms of symptom research and management and your programs interest.
Dr. Bruera: Right, well we are very interested in trying to develop new ways of helping patients in this stage of the disease when really the cure is not anymore the goal but improving the way patients feel is the goal. So we are conducting for example randomized control trials trying to understand if hydration near the end of life is superior to no hydration. Almost a hundred percent of us will die if we die in a hospital with intravenous hydration. Almost none of us will die with hydration if we die in hospice. And we believe that probably this zero percent, one hundred percent difference is not very sensible and there must be some people who really benefit and some people who do not benefit. So we're doing a study trying to address the value of hydration on a double blind basis. We're also studying the value of nursing phone calls and/or a little bit of methylphenidate for the management of cancer fatigue. We're conducting comparisons between the first line use of morphine versus methadone as an opiate analgesic. We're studying spirituality as a need both as a source of comfort and as a source of distress in outpatients receiving palliative care. We're conducting some studies on the multi-modal interventions for fatigue and for cachexia in our patients combining exercise, nutrition, natural light and pharmacological interventions. So we have a wide variety but the vast majority of our research is focused specifically on well being and symptom management in patients who are very advanced in the trajectory of their illness.
Dr. Baile: I think that the research and the approach that your unit has, has really helped put the spotlight on the fact that just because a patient is dying, that doesn't mean that we can't give them a quality of life as best as they can have and that we can really focus on symptom management as one way of really having patients have their last hours and last days and last months in a way that they can accomplish goals that they might have. Would you say that that's really been an important like change in how we think about the dying process?
Dr. Bruera: Absolutely. And that's exactly the point. The idea of the dying process being a kind of a passive moment in which people transitioned into the bedridden state where they stood there waiting for death to come has been replaced by a concept of increasing our ability to express our maximum potential, social potential, symptom potential, functional potential. And we are being much more successful than we were only 10 or 15 years ago in allowing our patients to have a life after the cancer treatment even though the disease is progressing. And as you very well point out, our patients achieve many goals of quality of life and family and personal issues addressed during those weeks that precede the end of life.
Dr. Baile: Well thank you very much. I know that in your lecture that you'll be talking about other aspects of families and patients concern toward the end of life. So I'd like to thank you for enlightening us on the aspects of care of your department and some important information about symptom management and palliative care and what we can look forward to. You can find out more about the Department of Palliative Care and Rehabilitation Medicine on the M.D. Anderson website www.mdanderson.org. You'll also be able to view Dr. Bruera's lecture, "Patients and Families Facing End of Life" and receive free CME credit on our I*Care website at www.mdanderson.org/icare. Look for it under our Achieving Communication Excellence lecture series. Thank you again Eduardo.
Dr. Bruera: Thank you.
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