Discuss hospice and palliative care with cancer patients
PALLIATIVE MEDICINE M A Y 2 0 0 9 • H O S P I T A L I S T N E W S
Expert Sizes Up Palliative Care Medications
B Y P AT R I C E W E N D L I N G
a PPI if the patient is on a steroid or non-
tients, especially women, and in those re-
ications relevant to palliative care have
Ǡ Sancuso is a transdermal patch de-
Propoxyphene is far from benign, Dr.
dive dyskinesia, Dr. McPherson said.
Ǡ Tapentadol, a centrally acting anal-
drug and its metabolite are cardiotoxic.
Administration last fall, the patch is ap-
Ǡ OTC products. Emuprofen is a topi-
cally administered analgesic that contains
and can be worn for up to 7 days. In clin-
ibuprofen and oil from the fat of the emu.
It’s being marketed as an anti-inflamma-
Ǡ Dexlansoprazole (Kapidex) delayed-
ditions. Cost is about $35 for a small jar.
Ǡ Tramadol is not a controlled sub-
stance at the federal level, but it may be
heading that way, Dr. McPherson said.
been reported in up to 15% of patients.
disease. This R-isomer of lansoprazole
dol) is the mainstay for nausea, she said.
Ǡ Zolpidem (ZolpiMist) 5-mg and 10-
hibitor (PPI) with a dual delayed-release
ment of difficulties getting to sleep. The
neck cancer. The active ingredient is xyl-
a day, versus 15-30 mg a day for Prevacid.
levels within the body in 15 minutes. Pa-
Ǡ Propoxyphene may be on the chop-
hours in bed after receiving the drug.
mittees narrowly voted on Jan. 30 to rec-
Ǡ Metoclopramide products, which in-
practice in a hospice on a PPI they don’t
and injections, received a black box warn-
is the equivalent of two regular-strength
death,” said Dr. McPherson, a professor
tients at the end of life typically are treat-
prescribed drugs in the United States, Dr.
pill, [but] it doesn’t work any better than
cians like it because it causes less stom-
Discuss Hospice and Palliative Care With Cancer Patients
B Y P AT R I C E W E N D L I N G
Reimbursement is also a thorny issue. The Medicare
tice for years, and noted that the American Society of
reimbursement for hospice and palliative care hasn’t
Clinical Oncology now makes these plans available on-
A U S T I N , T E X . — Some palliative chemotherapy
kept pace with inflation or current oncology practice
line (www.asco.org). The Centers for Medicare and
regimens can cost up to $100,000 a year for end-of-life
trends, even though patients with cancer account for
Medicaid Services system is also starting demonstration
care. Yet oncologists and their patients often do not dis-
about 40% of Medicare drug costs, Dr. Smith said. On-
projects, so physicians can get paid more if they write
cuss less costly, alternative advanced-care options.
cologists are reimbursed far more for administering
down their treatment plans, he said.
“This is going to come to the fore over the next year
chemotherapeutic agents than for having discussions
During the same presentation, Dr. Sarah E. Har-
or two, as fewer and fewer people have insurance,” Dr.
about prognosis and palliative care options.
rington offered suggestions for what oncologists should
Thomas Smith said at the annual meeting of the Amer-
ican Academy of Hospice and Palliative Care Medicine. If hospice is introduced early in
“We spend twice as much as any other country for the
treatment as an end-of-life
He noted that some insurance companies may soon
option, patients tend to switch
be asking patients to pay more for third-line treatments
earlier and spend more time in
because of their reduced possibility of benefit. If hos-
pice is introduced early in treatment as an end-of-life
hospice, thereby reducing
option, moreover, patients tend to switch earlier and
patient and hospital costs.
spend more time in hospice, thereby reducing patient
and hospital costs. Currently, one-third of patients
with cancer spend fewer than 7 days in hospice, he said.
going to be dead within a year . and suggest hospice
rington, also at Virginia Commonwealth.
A sea change may already be underway. Kaiser Per-
and palliative care?” he asked. “I’ve been beating on the
The subject of hospice should be brought up early
manente has put hospice and palliative care teams in all
NCI for 15 years on this, and will probably die before
as part of routine oncologic care, rather than delayed
of its major markets, and many insurers (such as Unit-
until death is imminent. Oncologists should be espe-
edHealthcare) are expected to roll out their plans for
For those who say patients can’t handle the truth, Dr.
cially realistic about nth-line chemotherapy. If no
concurrent oncology and palliative care later this year,
Smith said it is nearly impossible to take away hope.
proof of benefit is available, don’t offer it, she said.
said Dr. Smith, professor of palliative care research at
Most cancer patients are overly optimistic about their
To avoid feelings of abandonment, oncologists should
Virginia Commonwealth University in Richmond.
prognosis and are willing to take a phase I drug, even
tell their patients they will not abandon them if they
Part of the problem is that neither oncologists nor pa-
if it has a 10% chance of killing them.
tients want to talk about death. A recent study showed
New data suggest that one of the biggest fears of the
Dr. Harrington and Dr. Smith referred the audience
that oncologists discussed prognosis 39% of the time and
terminally ill is abandonment by their physician or
to a recent article in which they discussed questions pa-
impending death only 37% of the time ( JAMA 2008;300:
nurse when disease-modifying therapy is no longer an
tients should consider when asking about palliative
1665-73). Of 111 inpatients with cancer, only 23 said they
option (Arch. Intern. Med. 2009;169:474-9).
chemotherapy, and what oncologists should or should
wished to discuss their advanced-care preferences with
Written treatment plans offer patients truthful in-
not do or say about chemotherapy for advanced can-
their oncologists, and 64 said they would prefer to do so
formation about prognosis and treatment effective-
with an admitting doctor ( J. Palliat. Med. 2000;3:27-35).
ness, Dr. Smith said. He has been using them in his prac-
They reported no financial disclosures.
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