Promoting Excellence : Integrating Cancer Care and Palliative Care : M.D. Anderson Cancer Center

"I love the blend of the medical and the psychosocial in this field. I love learning. This field is in its infancy. There is lots to learn and lots to offer.”

--Donna S. Zhukovsky, MD

Institution
M.D. Anderson Cancer Center
Houston, Texas

Program
Department of Symptom Control and Palliative Care

Year Started
The department started in 1999 but was not fully staffed until 2000.

Patients Seen
No data yet

Director
Eduardo D. Bruera, MD
Department Chair
713-792-6084
ebruera@mdanderson.org

Program Mission and Objectives
To help patients and families diminish their physical and psychosocial distress and to allow them to maintain their maximal autonomy and dignity. The program’s vision is:

To become a model of clinical excellence and a resource to patients, families, caregivers and physicians within M.D. Anderson Cancer Center (MDACC), Texas and the world.
To train and educate physicians to become future leaders in the field of palliative care in the US and throughout the world.
To conduct clinical and outcomes research and to develop new methodologies for research in palliative care.
To educate and inform physicians, health care providers, administrative and support staff, patients and their families about the availability and benefits of palliative medicine.

Program Description
Inpatients and patients at home who cannot travel have access to a mobile consultation team (physician, advance practice nurse and fellow) that provides rapid assessment and management of physical and psychosocial distress.

Outpatients have access to interdisciplinary assessment in the Symptom Control and Palliative Care Center. The interdisciplinary team includes a physician, nurse, pharmacist, dietitian, chaplain, speech pathologist, occupational therapist and physical therapist. The center’s ultimate goal is to return patients to their homes (or inpatient room, in some cases) with a clear, personalized plan for palliative care.

The center does not have a common waiting area. Upon arrival, the patient and family are escorted into a comfortable private room where individual team members visit them. The assessment is audiotaped so the patient and family have a permanent record. Following the assessment, specific written recommendations are given to the patient and family.

Historical Perspective
Prior to the arrival of Eduardo Bruera, MD, Richard Payne, MD, headed up the MDACC symptom control section, which was housed in the neurology department. When the institution decided to focus more on end-of-life and palliative care, the section was moved to the division of anesthesia and critical care and was elevated to department status.

Donna A. Zhukovsky, MD, says that the department is a “work in progress,” with the same challenges that face any palliative care effort—challenges that are often shaped by geographic location, demographics of the patient population and the prevailing culture of care. Although the commitment to develop the department emanates from the highest levels at MDACC, Zhukovsky explains that she and her colleagues are mindful of two important facts. The first is that patients coming to MDACC are seeking aggressive care; they are seeking to live, not preparing to die. Consequently, it is important to discuss palliative care and hospice with patients in the context of how one lives within the constraints of the disease.

The second reality is that MDACC flourished in the past without a palliative care program. MDACC physicians must be educated about palliative care and how it fits into their practices. To this end, Bruera and his colleagues have been working with a management consultant to identify program champions and stakeholders and to develop a plan for implementing organizational changes.

Research
The department has multiple studies ongoing, some at MDACC and some in Latin

America. Topics include research on patient communication, screening tools for depression, dyspnea, nurse and family perceptions of patient comfort levels, fatigue and exercise.

Education
With a grant from the Texas Cancer Council, MDACC and other health care providers in the area are participating in “bus rounds.” A group of providers travel via bus to see three to four patients who have consented to participate in the program. Members of the group enter the patient’s home and discuss the case. The discussion is broadcast back to the bus, where others listen. Between stops, everyone discusses the cases they are seeing that day.

The department recently hosted the first in a series of videoconferences, in which MDACC palliative care experts shared their knowledge with health care professionals in Argentina, Columbia and Uruguay.

In terms of community education, Zhukovsky is developing a course on patient care for family care providers, which will be available before the patient is discharged from the hospital.

Partnerships
The department/center partners with other health care providers in the community.

Marketing
The program is implementing a communications strategy inside the institution but is not marketing outside the institution.

Funding
The program is funded by patient revenue (25%), institutional support (13%), and grants and philanthropy (62%).

Vision
In the future, a palliative care unit will provide intensive support to patients in severe distress, and to their families. The unit will have an interdisciplinary structure with access to physician, nurse, social worker, occupational therapist, psychiatric/psychologic therapist, speech pathologist, nutritionist and chaplain. The unit will play a major role in educating physicians and clinicians in training.

Planning is also underway for Houston area patients to receive home care or inpatient hospice care via a number of MDACC-affiliated caregiving organizations, including hospices, home care agencies and community-based physicians. Patients who return to their own communities to receive palliative and hospice care will have access to interdisciplinary assessment at MDACC. The MDACC palliative care team will make recommendations to the patient and family as well as to the local treating physician. In addition, telemedicine arrangements will be made to advise local physicians about palliative care issues.

A National Perspective
Elements and Measures of Program Success
Support from the top and grassroots champions are essential. Both flexibility and perseverance are critical.

Necessary Steps

Advocacy to create demand at the community level.
Accountability—e.g., questions on the oncology boards and certification exams; JCAHO standards; National Cancer Institute program requirement.
People with the expertise to teach others.
Application of evidence-based medicine.

What I Wish I’d Known Then . . .

“I wish I knew more about organizational change. Understanding the psychology of institutions is important.”

--Donna S. Zhukovsky, MD

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.