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June Elizabeth Connolly MSN CCRNStaff Nurse MICU, UPMC Presbyterian-ShadysidePittsburgh, PA

The Oncology Patient in the ICU: Step Forward to Combine Palliative Care and Aggressive Therapies

UPMC Shadyside~ Pittsburgh, PA

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• Defend the right of the patient to receive the best of all therapies including palliative care

• Justify the use of palliative care not just during the last few days of life but along a continuum from diagnosis to resolution of illness

• Describe the synergy created between palliative care and aggressive therapies when employed together

• Predict a less difficult course for those patients who have comprehensive palliative services from the onset of illness forward

• Recognize that palliative interventions employed in the face of critical illness can actually prolong life

Objectives

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• Have chosen the AML patient and here is why!

Three Case Studies

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• They represent a significant portion of our patient population

• The disease is often fatal• Their care is complex• The drugs are toxic

Why the AML Patient?

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• National Cancer Institute ~ – 13, 780 people would be diagnosed with

acute myelogenous leukemia (AML) in 2012

– 10,200 would die in 2012 – 2004-2008- median age of diagnosis for

AML was 67y

Reference: National Cancer Institute, U.S. Institutes of Health (2011). Surveillance Epidemiology and End Results, Stat Fact Sheets, Acute Myeloid Leukemia Retrieved April 16, 2011 from : www.cancer.gov

Prevalence

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• Author of “The Emperor of all Maladies”

Who is Siddhartha Mukherjee?

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• In the mid 80s to early 90s oncology patients admitted to intensive care units

• Tom Starzl “organ bouquets”

Bone Marrow Transplant was the chemo answer

Critical Cancer Care

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• Malignant cell in AML is the myeloblast • Normal hematopoiesis~

– myeloblast is an immature precursor of myeloid white blood cells (granulocytes)

Neutrophils BasophilsEosinophils

– transforms into a mature white blood cell

Pathophysiology

Hematopoiesis“Hematopoietic

stem cell”

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• In AML, a single myeloblast accumulates genetic changes which "freezes" the cell in its immature state

Failure to differentiate +

Over-proliferation (uncontrolled growth of immature clone cells or “blasts”)

=Acute myelogenous leukemia

Pathophysiology

blasts

Circulating Leukemic Cells or “Blasts”

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• Chemicals – Benzene

• Chemotherapy drugs – etoposide – alkylating agents

• Radiation• Genetics• Down syndrome• Immunosuppression

Increased risk for AML with:• Polycythemia vera• Essential thrombocythemia• Myelodysplasia(refractory anemia)

Causes of AML

• Remission Induction Therapy– Chemotherapy regimens– Eradicate the leukemic clone– Return proper function to bone marrow – Goal is to “induce” a complete remission

(CR)

Treatment Recommendations

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• Remission Consolidation Therapy – Goal of maintaining CR, achieving a cure

by suppressing microscopic disease– High dose chemotherapy– Combination of chemo + Hematopoietic

stem cell transplant (HSCT)

Treatment Recommendations

• Many cancers are now chronic diseases• Pts. live longer due to treatment

advances• Intensivists and Oncologists must

collaborate

Critical Cancer Care

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• New critical care concepts for cancer patients–Palliative and intensive care co-exist

–Palliative care different from Hospice

Critical Cancer Care

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• WHO in 1990 unfortunately described Palliative care as “care for those who did not respond to curative treatment”.

• Many doctors are frozen like the myeloblast

• See Palliative Care as synonymous with Hospice which it is not

Quality of life

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• To cure disease and provide comfort care widely thought to be mutually exclusive!

• The best of all life sustaining therapies should be offered to our pts., including Palliative Care*

Quality of Life

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Goya’s La Nevada o El Vierno. Museo del Prado

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Palliare is the Latin root meaning “to cloak”

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• Studies show that pts. receiving early palliative care not only have a better QOL but live longer

Cohort of 151 Patients

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• Patricia Smith 78 y old woman• Diagnosed with AML several years ago• Has never been offered Palliative Care• On “maintenance chemotherapy”• Presented to the ED with neutropenic fevers • Loss of appetite• CXR shows “mass LUL”

Case Study 1

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• Dx as having an invasive aspergillus PNA

• To MICU following a “Condition C” for respiratory distress

• Code Team found her lying flat on gurney

• Awaiting MRI of brain

Case Study 1

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• O2 sats 95% on 6L NC• New onset confusion/agitation• Few slurred words• Rales on auscultation

Case Study 1

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• WBC 0.6• Platelets 17,000• Hgb 7gms• Pancytopenia with 1% blasts• K+ 3.3

Labs at that time

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• Acyclovir • Caspofungin for Aspergillus• Cefepime and Vancomycin for PNA• Blood Cultures negative• Replete K+• Platelet transfusion for thrombocytopenia• PRBCs for low Hgb

Therapies

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Pt. had previously stated: “ I want everything done”.

• Shouldn’t we ask what ‘everything’ means?

• Excellent symptom management from a team of experts?

• Support for patient and daughter?• Attention to quality of life and relief of

suffering should occur simultaneously with onset of therapy

• Medical Ethics/Palliative Care on board immediately

• Worsening respiratory status• Pulmonary edema • Increasing oxygen demands• Daughter makes pt. DNR/DNI• Pt. lives another 24h

Case Study 1

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How could this patient have been managed better?

Case Study 1

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• Palliative care referrals oftentimes occur very late

• When patients too debilitated to tolerate further therapy

• When no more options available

Palliative Care Referral

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• JC is a 62y old male with a PMH of AML• BMBx August 2007• AML Dx August 2007• Autologous HSCT 2009• MUD stem cell transplant 2011• Pt. has GVHD involving gut and liver

Case Study 2

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• CMV • C Diff Colitis• GVHD

Co-morbidities

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• EMS arrive at pts. home• Pt. requests Lasix for dyspnea • Wants to remain at home to die• Paramedics refuse treatment UNLESS pt.

hospitalized

Case Study 2

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• Extensive right sided infiltrates consistent with PNA

• Dyspneic and tachycardic• Rales throughout lung fields• Lasix and Morphine for comfort• Medical Ethics/Palliative Care referral for

support and symptom management

On admission to the ED

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• Pt. tells ED team he wants to die• BUT Oncology fellow tells team pt

wants to consider intervention for “anything that might be treatable”

Are these people on the same planet?

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• We acknowledge that aggressive therapies can and do relieve symptoms and prolong life

• When they no longer benefit patient we must stop them before they do harm!

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• When there is no longer any benefit to pt. we must stop before we do harm

To Repeat…

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• Admitted to the MICU• Has made himself DNR/DNI• Is considering Hospice• Oncology Fellow’s comment is “He’s not

quite there yet”

On the Same Planet, continued

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• Again pt. states he wants to die • Somebody is not listening!• This pt. is days if not hours from dying and

we are still arguing about treatment options• If quality of life was a priority throughout the

disease process these arguments would never take place

Not On the Same Planet, Continued

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• If we don’t have conversations about treatments options, the default is what we just witnessed

• Oncologists working to improve communication skills

Candid Conversations are Key

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• Who is left at the bedside?• Who often knows the pt. and family

better than anyone else?

While Others Are Sorting It Out…

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• Medical Ethics/Palliative Care immediately and effectively focus on relief from suffering

• Distress significantly lessened • Pt. asks, “Why wasn’t this offered to me

earlier?”• Pt. lives 48h longer

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Personalized Cancer Care

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• This is what should have happened:• A treatment plan consistent with evidenced

based options• JC’s informed preferences as part of the plan• As he reaches end of life, potentially harmful

therapies are stopped

• CS is a 25 year old waitress/grad student c/o nosebleeds and fatigue

• Collapses and is forced to go to the ED• CBC in the ED reveals 50,000 blasts• BMBx confirms AML• Experiences bone pain, anxiety, depression

Case Study 3

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• Medical Ethics and Palliative Care come on board to “help with a manipulative, drug seeking patient”

• They are involved for all the wrong reasons BUT

• Remain with the pt. and her family throughout her therapy including HSCT

Case Study 3

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• Pt. has no insurance• No means of paying rent• Loses her job• Must drop out of school

Cancer Related Distress

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• Pt. and parents worry about addiction as her brother is an addict

• Family dynamics: pt. says “yes” to narcotics but mother objects as she is worried “CS will become an addict like her brother.”

• Anxiety and Hopelessness over having an often fatal form of cancer

Cancer Related Distress

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• Isolation: Friends stop by to see her, don’t know what to say, drift away or busy with families, school, jobs.

• Chemotherapeutic drugs result in sterility• Grieving over what has been lost, health,

career, friends• Fear of impending death

Cancer Related Distress

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• Lots of work to do: pt., family and heme-onc team• Difficult to gain acceptance of drugs to treat pain• This was a pt. who got better and went home• Never any question that this was “end of life”

therapy• This was symptom management solely

Case Study 3

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• American Society of Clinical Oncology(ASCO) February 2011

• Logical to pursue symptom management and disease management simultaneously

• Many Oncologists see Palliative Care as synonymous with end-of-life

• Some people use the term “supportive care” as oncologists are distressed when you say “palliative care”!

Quality of life care is the right of all cancer patients

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• ASCO’s vision for 2020 recognizes “we have a long way to go”

• Problem: We cannot visualize how to integrate aggressive chemotherapy and symptom management

• “Cure versus Comfort” model not acceptable but many still cling to it!

American Society of Clinical Oncology

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Seamless integration of palliative care and comprehensive cancer care• Some oncologists say “I can do it myself”*• Congress model is multi-disciplinary team• “Seamless Integration” model better meets

pt. and family needs

Desired Goal:

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• Patients and families require consistent information

• Nurse may be the only one aside from family who really knows this patient

Critical Cancer Care

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• Cancer patient’s relationships with their nurses and doctors are personal and long term

• Increased collaboration between the nurse, patient, doctor, family

Sacred Trust

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•MICU nurse preparation – Attend same classes as oncology nurses

•

Critical Cancer Care

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• Robust intensivist program • Pittsburgh Cancer Institute 400 pts./day

– Medical Oncology– Surgical Oncology– Hematology-Oncology– Radiation Oncology– Transplant surgeons

Medical ICU

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• Mission Statement UPMC Presbyterian-Shadyside MICU. We are dedicated to:

• Finding a balance between aggressive therapies and palliative care

• Understanding that Oncology and Critical Care are two different disciplines with the same mission – working together for a better quality of life for our

patients.

Collaborative Efforts of the ICU-Oncology Committee

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We Have Evolved

• UPMC Shadyside’s MICU has evolved

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At UPMC Shadyside we are building bridges!

Our Fair City

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• Get involved • Get on board• This is your organization• Own it• Really make it yours!

AACN: A word about how I got here today

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• June Elizabeth Connolly MSN CCRN• Chapter Advisor Region 3• Senior Staff Nurse MICU• UPMC Presbyterian-Shadyside• Pittsburgh PA• 412 983 3600• connoje@comcast.net• Start thinking: NTI May 17-22 2014 Denver, CO• Save the Date: Chapter Leadership and Development Workshop (LDW)

Sunday May 18, 2014

Contact Info

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• Acute Myeloid Leukemia. Leukemia & Lymphoma Society, 1-7. Retrieved January 10, 2011, from http//www.leukemia-lymphoma.org

• Albrecht, T. (2012). Management of Cancer-Related Distress in Patients with a Hematologic Malignancy. Journal of Hospice and Palliative Nursing. 14(7), 462-468

• Armstrong, G.T. (2009). Facts 2009-2010. The Leukemia and Lymphoma Society, 1-25.

• Azoulay, E. (2003). Acute monocytic leukemia presenting as acute respiratory failure. American Journal of Respiratory and Critical Care Medicine, 167, 1329-1333. Retrieved January 12, 2011, from http://www.atsjournals.org

• Becker, G. (2011). Palliative Care: An Epidemiologic Study. American Society of Clinical Oncology, 29(6), 646-654. Retrieved January 1, 2013 from http://jco.ascopubs.org

References

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• Benoit, DD., (2005). Outcome in critically ill medical patients treated with renal replacement therapy for acute renal failure: comparison between patients with and those without haematological malignancies. Neprology and Dialysis Transplant, 20(3), 552-558. Retrieved January 10, 2011 from http://www.ncbi.nlm.gov/pubmed

• Brown, T. (2010). Critical Care. A New Nurse Faces Death, Life and Everything in Between. New York. HarperCollins.

References

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• Brown, T. (12/9/10). Elizabeth Edwards made wise choice to go home. CNN Opinion. 1-6. Retrieved December 10, 2010 fromhttp://www.cnn.com

• Brown, T., (October 13, 2010). When the nurse disagrees with the doctor. NY Times Well Post, 1-4. Retrieved October 25, 2010 from http://well.blogs.nytimes.com

• Bruera, E., (2010). Integrating Supportive and Palliative Care in the Trajectory of Cancer: Establishing Goals and Models of Care. American Society of Clinical Oncology. 28(25). 4013-4019. Retrieved January 1, 2013 from http://jco.ascopubs.org

• Bruera, E., (2012). Palliative Care in Advanced Cancer Patients: How and When? The Oncologist. 17(2). 267-273. Retrieved January 1, 2013 from www.the oncologist.com

References

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• Cairo, M.S., (2010). Improving outcomes for patients with tumor lysissyndrome. Speaker Program Series.

• Debono, D. (2011). Integration of Palliative Medicine into Routine Oncological Care: What Does the Evidence Show Us? American Society of Clinical Oncology. 7(6). 350-355. Retrieved January 1, 2013 from http://jop.ascopubs.org

• De Botton, S. (1998). Incidence, clinical features and outcome of all trans-retinoic acid syndrome in 413 cases of newly diagnosed acute promyelocytic leukemia, Blood, 92(8), 1-5.Retrieved February 24, 2011, from http://bloodjournal.hematologylibrary.org

References

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• Epstein, A.S. (2012). Palliative Oncology: Identity, Progress and the Path Ahead. Annals of Oncology. 3(43). iii43-iii48. Retrieved January 14, 2013 from http://annonc.oxfordjournals.org

• Federoff, A., Acute Myeloid Leukemia. 2010 Lecture. UPMC Shadyside• Greer, J.A. (2011). Effect of Early Palliative Care on Chemotherapy use

and End-o-Life Care in Patients with Metastatic Non-Small-Cell Lung Cancer. Journal of Clinical Oncology. 31(4). 1-7. Retrieved January 14, 2013 from http://jco.ascopubs.org

References

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• Jacobsen, P.B., (2012). A New Quality Standard: the Integration of Psychosocial Care into Routine Cancer Care. Journal of Clinical Oncology. 3(11). 1154-1159. Retrieved January 7, 2013 from http://jco.ascopubs.org

• Jessell, S., Difficult Conversations: How to Deliver Bad News. Lecture 2013. Hillman Cancer Center

• Kissane, D.W., (2012). Communication Skills Training for Oncology Professionals. Journal of Clinical Oncology. 300(11). 1242-1247. Retrieved January 14, 2013 from http://jco.ascopubs.org

• Meier, D.E., (2012). Palliative Care and the Quality of Life. American Society of Clinical Oncology. 29(20). 2750-2754. Retrieved January 14, 2013 from http://jco.ascopubs.org

References

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• Mukherjee, S. 2010. The Emperor of All Maladies. A Biography of Cancer. New York. Scribner.

• Myelodysplatic Syndromes., Leukemia & Lymphoma Society, 1-12. Retrieved January 10, 2011 from http://www.leukemia-lymphoma.org

• National Cancer Institute. July 8, 2010. Adult acute myeloid leukemia treatment. U.S. National Institutes of Health, 1-3. Retrieved February 8, 2011 from http://www.cancer.gov.

References

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• Palalay, N.K. (2008). Prognostic factors and utility of scoring systems inpatients with hematological malignancies admitted to the intensive care unit and required a mechanical ventilator. Hawaii Medical Journal, 67(10). Retrieved January 10, 2011 from http://www.ncbi.nlm.gov/pubmed

• Peppercorn, J.M., (2011). American Society of Clinical Oncology Statement: Toward Individualized for Patients with Advanced Cancer. American Society of Clinical Oncology. 29(6) Retrieved January 1, 2013 from http://jco.ascopubs.org/content/29/6/755.full

References

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• Rhee, C.K. (2009). Risk factors for acute respiratory distress syndrome during neutropenia recovery in patients with hematologic malignancies. Critical Care, 13(R173), Retrieved January 10, 2011 from http://ccforum.com

• Rickenbacher, E.J. (2001). Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors. Swiss Medical Weekly, 131(37-48), 681-686, Retrieved January 10, 2011 from http://www.ncbi.nlm.gov/pubmed

• Roze des Ordones, A.L.(2010). Clinical characteristics and outcomes of patients with acute myelogenous leukemia admitted to intensive care: a case-control study. BMC Cancer, 10:516.1-11. Retrieved January 5, 2011 from http://www.biomedcentral.com

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• Smith, T.J., (2012). American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of Palliative Care into Standard Oncology Care. Journal of Clinical Oncology. 31(4), 1-9. Retrieved January 14, 2013 from http://jco.ascopubs.org

• Subhash, H.S. (2003). Patients with hematological disorders requiring admission to medical intensive care unit: characteristics, survival and prognostic factors. Indian Journal of Critical Care Medicine, 7(2), 88-93. Retrieved January 10, 2011 from http://www.ijccm.org

• Thakker, S.G., (2008). Survival and predictors of outcome in patients with acute leukemia admitted to the intensive care unit. Cancer, 12(10), 2233-2240, Retrieved January 10, 2011 from http://onlinelibrary.wiley.com

References

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• Triulzi, D.J., Transfusion Support in Hematology/Oncology Patients, 2010. Lecture. UPMC Shadyside

• Von Bergwelt-Baildon, M., (2010). CCC meets ICU: Redefining the role of critical care of cancer patients. BMC Cancer, 10(612), 1-5. Retrieved January 12, 2011 from http://www.biomedcentral.com

• Yarbro, C.H., Wujcik, D. and Gobel, B.H. 2011. Cancer Nursing. Principles and Practice. Sudbury, MA. Jones and Bartlett.

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Lab work -• Lytes, uric acid,

glucose, BUN/CR• LFTs• Ca++, phosphorus • PT, PTT, fibrinogen,• D-dimer • Herpes simplex and

cytomegalovirus (CMV) serology

• Human leukocyte antigen (HLA) typing

Diagnostic tests -• Bone marrow biopsy• CXR • ECG • 2-D echocardiography • MUGA scan• Lumbar puncture • CT/MRI

Diagnosis of AML & Workup for Chemo

Classification of AML

• 1976 - FAB (French American British) AML classification system – Divides AML into 8 subtypes M0 through M7 – Based on cell morphology and its degree of

maturity • 1999 - WHO (World Health Organization)

classification system– Based on combination of morphology,

cytogenetics, molecular genetics, and immunologic markers

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Step Forward

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• Aztreonam• Lasix• Morphine • Vancomycin• Prednisone• Cellcept• Tamiflu• Zoloft

In Hospital Meds

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• Flomax• Trazadone• Gancyclovir• Voriconazole• Cefepime• Cyclosporine• Insulin• Nifedipine