This webinar provides insight and guidance into the challenges of advanced cancer in patients nearing the end of life.

1. title for presenter name,
title and date
Advanced Cancer
at End of Life

2. CE Provider Information
VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS
Healthcare Corporation of Florida, Inc/CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home
Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists
through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home
Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare programs in California/Connecticut/Delaware/Illinois/Northern Virginia/Ohio/Pennsylvania/Washington DC/Wisconsin are
provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social
work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education
(ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/18 - 06/06/21). Social
Workers participating in this course will receive 1 clinical continuing education clock hour(s). {Counselors/MFT/IMFT are not eligible
in Ohio}
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of
Registered Nursing, Provider Number 10517, expiring 01/31/2019.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH:
No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois

3. Goal
Describe and document the factors that qualify oncology patients as hospice appropriate.

4. • 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 in advanced cancer
Objectives

5. • 67 year-old male who presented to his Primary Care Physician (PCP) with the following
complaints for past month:
– Cough
– Shortness of breath with exertion
– Mild to moderate left shoulder pain
Clinical Case

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

7. • Married
• One adult daughter
• One nine-month-old grandson
• Works at tee-shirt printing company
Social History

8. • Initial workup by PCP
– Chest X-ray that revealed left upper lope (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
Diagnostic Workup

9. Oncology Plan of Care
• Full staging work PET scan reveals:
– Locally advanced NSCLC
• Norco 5/325 mg, one PO every four hours as needed for left shoulder pain
– Symptom management
• Norco 5/325 mg, one PO every four hours as needed for left shoulder pain

10. • Patient admitted to hospital with:
– Nausea
– Vomiting
– Constipation, no BM x six days
– Dehydration
– Anorexia
– Weight loss x eight pounds
– Increasing left shoulder pain
S/P Chemo-Xrt One-Month Follow UP

11. Hospital Course
• Treatment
– IV fluids
– Ondansetron six mg every six hours PRN nausea
– Miralax
– Enemas
• Discharged home on day four

12. • Nausea, improved using ondansetron
• Weakness, spends 12 hours/day in bed or recliner
• Not eating well but taking PO fluids throughout the day
• Norco 5/325 mg, taking eight per day with left shoulder pain 7/10
• ECOG 3, chemo held
• Follow-up appointment in three weeks for reassessment
Post-Hospital Oncology Visit

13. • ECOG two
• Reports feeling better
• Decision to proceed with CXT with 25% dose reduction
Oncology F/U 3-Week Visit

14. • Vomiting
• Diarrhea
• Inability to take PO
• Left shoulder pain 9/10
• New low thoracic back pain for three days, unable to move
• Dehydration
• T10 new pathologic fracture
Post-CXT 1-Week Onc Visit

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

16. • Due to poor performance status ECOG 4, no cancer-directed treatment can be provided
at this time
• Recommend that he “go home and get stronger,” follow up outpatient to reassess
• Continue Norco PRN for pain
• Encourage nutritional supplements
• Discharged home with home health and physical therapy (PT)
Oncology Care Conference

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

18. Family Concerns
• Family contacts oncology office with the following:
– Patient cannot come to office due to extreme weakness, debility, and pain
– Oncology reports “there is nothing more that can be done”
– Refers to hospice; patient dies within four days of hospice admission

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

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

24. Hospice as an Active POC
• PT evaluation for home safety and education of 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 quality of life (QOL) and function
– COPD as comorbidity also contributes to function and prognosis

27. Hospice as an Active POC (Cont.)

28. Hospice as an Active POC (Cont.)
• Medication review
– Optimization of pain control, long-acting opioid and immediate-acting opioid
– Addition of gabapentin for nerve-related pain from brachial plexopathy
– Bowel regimen to avoid further constipation episodes
– Remeron low dose as appetite stimulant and to aid with sleeping
– Titrated antihypertensive to lower dose, given patient’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 IVF
at home and reassess

29. Hospice as an Active POC (Cont.)
• RN visits patient three times the first week
• Teaches 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
• Notable improvement in the shooting, shock-like pain from brachial plexopathy with addition
of gabapentin and titration pursued slowly
• IVF time-limited trial (1 L) is effective, patient’s nausea resolves, increased energy, less
fatigue related to decrease in immediate-release opioids
• Bowel movements regulate, feeling of fullness resolves, improved PO intake
• SOB markedly improves with titration of O2 and oral opioids
• Appetite and sleep improved with Remeron nightly

30. Hospice as an Active POC (Cont.)
• Social worker visits, reviews patient and family concerns, identifies that wife is struggling.
Counseling is arranged for follow-up
• Chaplain makes contact, asked to follow up on second week, given they feel overwhelmed
by so much activity this first week. Appointment made for the subsequent week
• Hospice aide services offered. Given patient is better, defers at this time, but aware that as
things change this will be available and important

31. Hospice as an Active POC (Cont.)
• Two weeks after admission, patient feels and functions better, ECOG up to two, pain
controlled, wishes to speak with oncologist at urging of daughter visiting from out of state.
• Make appointment with oncologist and has frank discussion regarding how feeling better
and functioning better in order to best enjoy remaining life is critical. Defers on further
cancer-directed therapies.
• Patient is followed by hospice for two months before demonstrating further decline. During
this time, with the help of chaplain and social worker, all funeral arrangements are finalized.
• Patient able to enjoy time with grandson, memory making with help of volunteers so his
grandson will have keepsakes.

32. Hospice as an Active POC (Cont.)
Source: Temel, J., et al, N Engl J Med 2010;363:733-42.

33. Hospice as an Active POC (Cont.)
• Patient does well for additional two weeks at home, slowly declines, becomes more
lethargic, less interactive and dies peacefully surrounded by family and with hospice nurse
in attendance at his death.
• Bereavement services provided to family for 13 months post death
• Weekly updates are provided to the oncology team throughout the hospice course; they are
notified of patient’s death.

36. Substantial variation exists among providers in how hospice services are delivered
The Benefits of Hospice

37. The Benefits of Hospice:
Patient and Family Experience of Care
Patient and Family-Centered Reported Outcomes at the Last Place of Care (Cancer,
Heart Disease, Stroke, Dementia)
Study Conclusions: 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.
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
Source: Teno J. et al, JAMA, 2004.

38. References
• Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., ...
& Billings, J. A. (2010). Early palliative care for patients with metastatic non–small-cell lung
cancer. New England Journal of Medicine, 363(8), 733-742.
• Teno, J. M., Clarridge, B. R., Casey, V., Welch, L. C., Wetle, T., Shield, R., & Mor, V.
(2004). Family perspectives on end-of-life care at the last place of care. Jama, 291(1),
88-93.

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