Pain & Palliative Care
Relieving patients' acute distress is new unit's goal
Attending physician Doug Brandoff prepares to visit a patient.
Amid the morning hubbub of the nursing station on unit 5A at Brigham and Women's Hospital, a group of white-coated caregivers stakes out a spot to talk. Physician assistant Ian Nagus, PA-C, flips through a cancer patient's chart and reviews how she fared during the night, from her electrolyte levels to medications to measures of pain.
The patient's oncology team has ordered a CT scan of her brain to see if the disease has spread, and attending physician Douglas Brandoff, MD, pauses to let the rounding group ponder this development. "How are we going to share this with her? Does this feel like a potentially difficult conversation coming up? She wants to know what's going on, and we owe it to her to not beat around the bush."
This exchange on a recent spring morning is both a learning opportunity and a reflection of the attention these providers place on how their patients are feeling emotionally, as well as how they're doing physically.
Brandoff, Nagus, and their colleagues are part of the care team on the new Intensive Palliative Care Unit (IPCU) within the Dana-Farber/Brigham and Women's Cancer Center. The program serves cancer patients with distressing symptoms such as pain, nausea, shortness of breath, and delirium, and helps address emotional, social, and spiritual concerns these patients and their families may encounter during a life-threatening illness. The unit, which can accommodate up to 12 patients, is on 5A and 5B of Brigham and Women's Hospital.
While some IPCU patients are at life's end, others need acute care before going home or to a rehabilitation center.
Janet Abrahm
"We're providing around-the-clock, intensive, and coordinated care to cancer patients and families who are facing a physical or psychosocial crisis at any stage of their illness," says Janet Abrahm, MD, director of the DF/BWCC's Pain and Palliative Care Program. "This kind of program is very unusual, and we hope it will serve as a model for others around the country."
A team approach
After discussing the patient's upcoming CT scan, three members from the rounding group don medical gowns and gloves and enter her room. "Good morning," Brandoff says warmly, accompanied by Nagus and palliative care fellow Winnie Suen, MD.
While this trio visits the patient, the rest of the team checks electronic medical records or discusses medication dosages with Bridget Fowler, PharmD, a pharmacist who specializes in palliative medicine. They reconvene 20 minutes later and head down the hallway to the next patient. These morning rounds occur daily.
The palliative care unit first opened in March 2005 as a pilot program with six beds alongside six general oncology ones. Despite positive comments from patients ("The care was beyond our expectations," was one), it closed after eight months to assess staffing needs. Reopened in late February 2007, the unit is now larger and more fully staffed.
Today its team includes attending physicians, physician assistants, palliative care fellows, nurses, pharmacists, a social worker, a care coordinator, a psychiatrist, and a chaplain all trained in the specialized care of patients facing acute distress from their cancers.
When patients arrive on the unit, they meet with team members. "We want to get to know each family and their needs," says Abrahm. "'Tell us what's been going on,' we ask them. 'What are the challenges of caring for your loved one at home? What kind of resources will help you when he/she goes back home?'"
Eventually, the group hopes to offer music therapy services to help soothe patients' symptoms. In addition, a cadre of specially trained volunteers — who are now being recruited by Dana-Farber and Brigham and Women's — will provide comfort, support, and companionship to patients and families during their stays.
Deborah Yolin
PAs on the case
A key feature of the IPCU is the role played by licensed physician assistants, who collaborate with attending physicians and nurses to provide comprehensive and compassionate care. This includes conducting physical exams, administering drugs, writing prescriptions, ordering and interpreting laboratory tests, attending family meetings, and arranging for patient discharges, according to Dana-Farber's chief physician assistant, Deborah Yolin, PA-C.
The Institute currently has 25 PAs based in inpatient and outpatient care and research settings. The inpatient sites include DF/BWCC's Palliative Care Service and its Bone Marrow Transplant and Hematologic Malignancies programs, Yolin notes. Physician assistants have been providing clinical coverage since the setting of federal limits on the number of on-duty hours for hospital interns and residents.
For Ian Nagus, working as a PA on the Intensive Palliative Care Unit is appealing because "you can still have some idealism and be able to spend a lot of time with patients. Our patients and families are so appreciative."
Yolin says of the team: "It takes a special kind of person to work in the palliative care field. These are compassionate individuals who, in addition to addressing symptom management, focus time and energy on psychosocial and family support issues. Being a part of this groundbreaking service has been an incredible experience."
– Debra Ruder
(debra_ruder@dfci.harvard.edu)
