December 1, 2004
New inpatient unit focuses on intensive palliative care
Janet Abrahm, MD
Working within a new unit at Brigham and Women's Hospital, a team of experienced clinicians is caring for cancer patients who need intensive attention paid to their physical, social, psychological, or spiritual sources of distress or suffering.
The Intensive Palliative Care Unit (IPCU), a family-focused, pilot program for the Dana-Farber/Brigham and Women's Cancer Center, is the first of its kind in Massachusetts. Janet Abrahm, MD, and David Giansiracusa, MD, are serving as co-directors of the unit, designed to handle complex cases that can't be managed at home. The aim is to reduce discomfort while enhancing quality of life for patients and their families.
"This provides a unique opportunity for an interdisciplinary team of caregivers to coordinate efforts and provide intensive relief from suffering," Giansiracusa says.
The new unit, located on 5A at Brigham and Women's, can accommodate six palliative care patients alongside six general oncology patients. Nurses and other staff care for all 12 patients and collaborate with the palliative care team comprising physicians, advanced practice nurses, a pharmacist, chaplain, and care coordinator. The team works closely with each patient's oncologist to ensure continuity of care.
With the change, nurses were offered the choice to remain on 5A and receive training to care for IPCU patients, transfer to other BWH cancer floors, or provide outpatient care at Dana-Farber. "The nurses who chose to stay have an opportunity to join a small number of clinicians with expertise in pain and palliative care," says Eileen Molina, RN, BSN, nurse manager for the new program. Nurses have developed their skills by attending a two-day conference and receiving ongoing, one-hour training sessions. Guidelines have been established for treating the symptoms they are most likely to encounter, such as nausea, delirium, or breathing difficulties – especially in the middle of the night.
According to those involved, the new unit will enable Brigham and Women's to measure outcomes for cancer patients whose distress is managed in a centralized locale, and learn to apply this knowledge to other patients, such as those with heart or lung disease.
"Our care for patients facing intense suffering has traditionally been dispersed throughout the hospital, but recent medical literature says it should be centralized," explains Dianne Cerce, key administrator for the Dana-Farber/Brigham and Women's Cancer Center. "A unit that focuses on palliative care is advantageous both medically and financially, because care is provided more efficiently. We hope to expand this service beyond cancer to other specialties."
David Giansiracusa, MD
Individualized care
Although the word "palliative" may imply end-of-life care, the broader definition is "to soothe without curing." Patients on the IPCU are at various points in their cancer journeys.
David Roche, 47, whose treatments for throat and tongue cancer caused him unbearable pain last spring, is one type of individual the new unit will serve. "We were fighting fire with fire through the radiation treatments, and my throat was so sore I felt like I was swallowing razor blades," he says. "The regular protocol for pain just wasn't doing the job." Roche considered ending treatment until his oncologist, Marshall Posner, MD, sought help from Dana-Farber's Pain and Palliative Care Program. Janet Abrahm and Maureen Lynch, MS, RN, AOCN, shaped a care plan for Roche, provided emotional support, and connected him with community resources.
"My situation changed 180 degrees once Maureen and Dr. Abrahm got involved," Roche recalls. "The pain wasn't gone, but it became manageable." Abrahm and Lynch partnered with Roche's oncologist to develop an individualized care plan for this chapter of his cancer experience.
Abrahm explains that palliative care has a different focus from general oncology care. "Some patients will really benefit from being on a specialized palliative care unit, while others will best be treated by our consultative service for inpatient and outpatient cancer care. This new unit is an enhancement."
Patient, family focus
In the palliative care model, each patient's physical, emotional, and spiritual needs – as well as those of his or her family – are addressed and become part of the treatment plan. Patients are invited to express their values and goals and plan for future care, which can help them experience smooth transitions from hospital to home or other care settings.
When a patient is admitted to the IPCU, the family meets the care team in the new Howard and Michele Kessler Family Waiting Room so all can voice their concerns. "Oncologists tend to focus on the tumor, while palliative-care experts focus on quality of life," says Lynch. "It's very traumatic for a family to watch a loved one suffer. We give them tools and support, and allow them to express their wishes, even as goals change."
