UP FRONT
Advanced Practice Voices
In this section, nurse practitioners, pharmacists, physician assistants, and
other advanced practice providers discuss issues specific to their practices –
from implementing quality improvement initiatives to staying up-to-date in
the latest hematologic advances.
In this edition, Flannery Fielding, NP, discussess the partnership between
palliative-care and hematology specialists.
Partners in Care: Palliative Care and Hematology
My nursing career began on a dedi-
cated inpatient unit at Cedars-Sinai,
caring for patients with HIV/AIDS
at the tail end of the AIDS epidemic.
The veteran nurses on our floor
recalled multiple deaths on every
shift; fortunately, those days have
passed. Many of my patients – mostly
men – survived long enough to
develop cancer and needed treatment
for their malignancy, in addition
to the antiretroviral drug cocktails
and treatments for opportunistic
infections.
I remember one patient who
survived AIDS and was living with
end-stage renal failure, only to later
develop lymphoma. His life and
death started me on the path to prac-
ticing palliative care.
Working with him one night,
he confided that he was tired and
wanted to stop everything – his HIV
medications, his dialysis, and his
chemotherapy. He had been through
enough, he told me, and he just
wanted to rest.
it is for anyone with a serious illness,
anywhere along their illness trajectory.
For patients and their families, these
are some of the most vulnerable and
stressful moments of their lives. For
the health-care providers caring for
them, there may be feelings of help-
lessness or distress that they can’t do
more. Both groups need the support
of our palliative-care team; we are car-
ing for our caregivers while simultane-
ously attending to our shared patient
and his or her family.
Now, having spent the past seven
years as a palliative-care nurse practi-
tioner (NP) in a large teaching hospi-
tal, I have had the privilege of caring
for a diverse group of patients and the
good fortune to work with exceptional
clinicians.
Our team consists of palliative-
medicine physicians, NPs, and social
workers, and our inpatient consult
service sees patients wherever they
are admitted – from internal medicine
to cardiothoracic intensive care and
every unit in between.
Patients and their families, as well as
health-care providers – need the
support of our palliative-care team;
we are caring for our caregivers while
simultaneously attending to our
shared patient and his or her family.
Over the next several days, we
nursed him with love, humor, com-
panionship, and medicine to ease his
suffering. We were able to talk about
his wishes and to honor those wishes,
providing him with care that saw him
as a whole person much greater than
the sum of his medical issues. He died
peacefully, just as he wanted. It exem-
plified palliative care.
Caring for Patients and
Caregivers
Despite my early experience, pallia-
tive care is not just for those patients
who are nearing the end of their lives;
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Consulting providers ask for our
help caring for patients with serious
illness for two broad reasons: They
need our skills to treat the symptoms
caused by an illness or its treatment,
or they need our expertise eliciting
patients’ hopes and fears about where
they are in their illness trajectory and
what might lie ahead.
Supporting Vulnerable Patients
Regardless of where we see them or
for what reason, many of our pa-
tients have a cancer diagnosis – often
among a host of other medical issues.
Palliative medicine has been practiced
at Cleveland Clinic’s Taussig Cancer
Institute since its inception in 1988,
but it is only in the past few years that
our team has worked in tandem with
our solid-tumor oncology colleagues
as an embedded service. And it is only
in the past few months that we have
begun working as an embedded team
within the bone marrow transplant
(BMT) service.
Both projects are spearheaded by
Susan McInnes, MD, a staff physi-
cian on our palliative medicine team
who is trained as both an oncologist
and a palliative-medicine specialist.
The support of Navneet Majhail,
MD, MBBS, MS, the director of
our blood and marrow transplant
program and newly appointed
president of the American Society
for Transplantation and Cellular
Therapy, also has been vital.
In the new endeavor with our
BMT program, the goal is to extend
our expertise in supportive care to
a group of patients who tradition-
ally have had limited contact with
palliative-care services. As an embed-
ded service, we participate in interdis-
ciplinary rounds, provide education
and support, and work collaboratively
with the oncology team to give the
best possible care to patients and their
families at a time when they need it
the most.
The patients who are coming in to
the hospital for a BMT often have en-
dured long admissions for induction
therapy on our leukemia unit, are in
remission and (hopefully) finally feel-
ing well again, and are now willingly
submitting to the transplant process,
despite the risks.
For many patients with a hema-
tologic malignancy, BMT is the treat-
ment that will cure them; for others,
the outcome is less certain.
Our project focuses on reaching
patients undergoing allogeneic BMT,
as they represent the group most likely
to need our support in both the short
and long term. Our interactions with
them typically involve management of
symptoms, having focused conversa-
tions about what to expect from treat-
ment, or both. We also are seeking out
patients – regardless of where they
are in their transplant process – with
intractable symptoms that are not
adequately controlled with the array
of medications on hand. Our team is
available to support patients, families,
and our colleagues throughout the
journey from diagnosis to transplant
and even at the end of life.
Hope in Palliative Care
I am one of three palliative-care
providers sharing coverage of the
BMT service. As an NP with just a
few years of oncology experience as
a registered nurse caring for patients
with hematologic malignancies and
solid tumors, but with many years of
hospice and palliative care experi-
ence (including certification as an
advanced practice hospice and pallia-
tive care nurse), I have faced a steep
learning curve working with patients
scheduled to undergo transplant.
Fortunately, we collaborate with
a dedicated group of transplant NPs,
physician assistants, nurses, social
workers, and a rotating schedule of
physicians who are all highly skilled
and willing to help get us up to speed
with the ever-evolving landscape
of cancer care. That ranges from
simple questions like how best to
treat a headache in a patient who just
received a chimeric antigen receptor
T-cell infusion to big-picture ques-
tions like how to provide care that
will give patients the best chance of
survival while preserving their qual-
ity of life. Other issues center on the
ongoing struggle between the very
human desire to maintain hope and
the need to face one’s own mortality.
As clinicians caring for patients
who are willing to undergo BMT and
all that entails, how do we address
the potentially grim reality of a
patient’s illness and the limitations we
face, while also acknowledging the
remarkable gains we have made in
cancer care? These are questions that
I’m certain we will continue to grapple
with, and I’m just as certain that we
are more likely to find the answers by
working together. ●
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