Promoting Excellence : Integrating Cancer Care and Palliative Care : Ireland Cancer Center, University Hospitals of Cleveland, Case Western Reserve University

"I felt discomfort in handing off patients to hospice. It is a feeling of loss. I wanted to integrate hospice into overall care.”

--James K.V. Willson, MD

Institution
Ireland Cancer Center
University Hospitals of Cleveland
Case Western Reserve University
Cleveland, Ohio

Program
Project Safe Conduct

Year Started
Enrollment of patients began in June 1999.

Patients Seen
To date, 145 lung cancer patients have been enrolled in the project.

Principal Investigator
James K.V. Willson, MD
215-844-8562
JKW@po.cwru.edu

Project Director
Meri Armour, MSN
216-844-7836
Meri.Armour@uhhs.com

Program Mission and Objectives
To create a seamless transition from curative to palliative to end-of-life care for patients and families by bringing palliative principles into the acute-care setting and involving patients and families at an early stage in decision making. To achieve this goal, project directors at Ireland Cancer Center proposed the following four outcomes:

To integrate a large community-based hospice program (Hospice of the Western Reserve) and an acute-care comprehensive cancer center (Ireland Cancer Center) by establishing a new interagency, an interdisciplinary team (Safe Conduct Team);
To promote a seamless transition from curative to palliative care for dying patients and their families;
To help Ireland Cancer Center physicians and allied staff manage pain and other symptoms, improve their communications with patients and families regarding end-of-life care, and assess when and how to refer patients to end-of-life care/hospice;
To strengthen community awareness of the options for end-of-life care and of what constitutes “good care” during the final phases of life.

Program Description
Project Safe Conduct targets patients with advanced lung cancer. Patients who elect to participate in the project sign a consent form. The team consists of an advance practice nurse, social worker and spiritual counselor; patients also have access to a pain control specialist, a psychosocial counselor, and a psychologist. The family is engaged at the beginning and at various points throughout the process.

During the pilot study for Project Safe Conduct, baseline data showed only 13% of patients were in hospice at the time of death. That figure grew to 77% by winter 2001. During the same time period, the median length of stay in hospice increased from three days to 26 days.

Historical Perspective
From the beginning, Project Safe Conduct has been championed by James K.V. Willson, MD, director of the Ireland Cancer Center; Meri Armour, MSN, vice president of cancer services; and David Simpson, MSW, executive director of the Hospice of the Western Reserve (HWR). The project has tried to build on the experience of community hospice and to use hospice techniques early in the disease process. Thus, the Hospice of the Western Reserve has been deeply involved in the planning process. As Willson explains, acute care staff and palliative care staff had to learn each other’s paradigms to make the patient transition virtually imperceptible.

During a planning year, Willson and his colleagues met with the administrative director of the cancer center, the head of the HWR foundation, pain management experts, psychologists and others. Willson recalls these meetings as highly rewarding experiences during which the planning team articulated and integrated goals.

Research
A research nurse is involved in the project.

Education
Professional education associated with Project Safe Conduct includes programs for physicians, nurses and fellows. Community outreach includes special events, speakers and town hall meetings organized around end-of-life care themes.

Partnerships
Project Safe Conduct partners with the Hospice of the Western Reserve and Ireland Cancer Center.

Marketing
Marketing is still in the planning stages.

Funding
Funding for Project Safe Conduct comes from the cancer center and from national and community foundation grants.

Vision
James Willson’s long-range vision is to develop a strategy for mainstreaming palliative care so that it is offered to all cancer patients. He wants to translate what his team has learned in an academic medical setting into a community-based oncology setting. Willson has identified five regional programs affiliated with the cancer center that can act as satellite sites.

A National Perspective
Elements and Measures of Program Success

Success has been measured in terms of adequate pain control and timeliness of hospice referral. Willson and his colleagues have discovered a third measure: a reduction in family discord.

Necessary Steps

Integrate and apply what has been learned by hospice at the end of life earlier in the disease process.
Do a better job of transitioning people through the system.

What I Wish I’d Known Then . . .

“This has been a learning process for all of us. I wish I had known more about the discovery process—that is, how to measure impact.”

--James K.V. Willson, MD

“Yes, we have learned a lot. These things may seem obvious but they are not intuitive, at least not amongst my colleagues over the past 28 years. First, I have learned that the effect of a good team is synergistic. It’s not so much what the team does as it is the gestalt of the members’ ‘combinedness.’ Second, I know now that the spiritual care component is sorely needed by patients and families. I had significantly underestimated its importance. Lastly, I have been greatly impressed with the support and enthusiasm physicians have for high-quality end-of-life care when they themselves are being supported in the process. Patients deserve both high-quality, high-tech cancer care and high-quality, highly engaged palliative care simultaneously.”

--Meri Armour, MSN

This descriptive summary is based on an interview conducted by Jane Grant Tougas with project staff in January and February 2001.

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit PromotingExcellence.org for more resources.