UP FRONT
Hematology Link
In today’s health-care environment, no practitioner operates in a silo – and that
is particularly true for hematology. In “Hematology Link,” we will speak with an
outside specialist to examine where these medical specialties meet.
Integrating Palliative Care
In this edition, ASH Clinical
News speaks with Douglas E.
Brandoff, MD, co-director of the
Adult Palliative Care Clinic at the
Dana-Farber Cancer Institute,
about integrating palliative care
into the management of people
with hematologic disorders. Dr.
Brandoff is a board-certified
palliative medicine physician and
hematologist/oncologist.
Douglas E. Brandoff, MD
What are the goals of palliative care?
Palliative care clinicians treat physical
symptoms (pain- and non-pain-related)
and also aim to alleviate psychological,
social, and spiritual suffering experienced
by patients facing a serious and lifealtering illness. Palliative care is available
at any stage of serious illness, from the
time of initial diagnosis and throughout
disease-modifying treatment, including
care with curative intent. We work as
an interdisciplinary team comprised of
physicians, nurse practitioners, nurses,
social workers, chaplains, physician
assistants, and pharmacists. We focus
upon the values, wishes, and goals of
patients and their family members, and
enhancing quality of life as they define
it. We emphasize collaboration and
communication with the patient’s primary
treatment team and support their ongoing
delivery of care.
Our goals are to assess a patient’s
total pain experience. We look at pain
from a multidimensional perspective:
“How is this affecting a patient physically,
psychologically, socially, and spiritually?
How is the pain interfering with the
patient’s daily functioning? How is it
impacting his or her quality of life?” By
taking a complete history across those
different domains, we can often reduce
the pain to a more tolerable level that is
acceptable and meaningful to the patient.
Another primary goal is to assess
a patient’s understanding of his/her
illness, treatment options, and likely
disease trajectory. We can help identify
questions and concerns the patient
may have about his or her condition,
treatment, and/or prognosis, and then
facilitate communication with the treating
hematologist. Between us, we can then
determine how best to address these
important questions.
I like to think of the collaborative,
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ASH Clinical News
collegial relationship as fluid, intertwined,
and flexible, where primary palliative care
is provided by the hematologist as part of
the care plan up front, and specialty-level
palliative care support is readily available
when needed. For example:
• when a patient receives treatment with
highly emetogenic chemotherapy,
the hematologist provides symptombased palliative care by ordering antinausea medications
• for a highly anxious patient, the
hematologist may pre-medicate before
performing the bone marrow aspirate
and biopsy
• for a patient experiencing sicklecell-related pain, the hematologist
provides pain management
However, there are also circumstances
where specialty-level palliative care can
further advance the care already being
given by the hematologist – both with
symptom management and psychosocial
support. This specialty-level palliative
care involvement may be episodic and
intermittent, or instead may be ongoing,
longitudinal, and co-managerial.
When should the hematologist contact the
palliative care specialist?
It is helpful to first meet before
collaborating on any specific patients,
for collegial introductions, and to
better understand one another’s patient
population and scope of practice. As a
palliative care physician, I like to know,
“What are some challenging symptom
management issues that you face in your
practice? Are there symptom management
or trajectory-of-illness communication
issues where you ‘get stuck?’ Are there
consistent areas where a collaborative
approach would be helpful to you?”
This helps me better understand the
hematologist’s needs, and also gives him/
her the opportunity to ask me about my
approach within palliative care. Our work
in palliative care can touch upon sensitive
topics, and it is important for referring
colleagues to feel comfortable and know
what to expect from a palliative care
specialist.
These conversations can help us find
opportunities where we might work
together, either for specific patients,
or in developing a routine clinical
By virtue of
treating a
hematologic
disorder – even
with curative
intent –
hematologists
are engaging in
palliative care.
pathway for the palliative care team’s
involvement when specific clinical issues
arise.
I think there are a few scenarios
when the palliative care specialist may be
especially helpful in collaborating on a
hematologic patient:
• if the patient’s pain symptoms
seem particularly multi-factorial or
complicated
• if you feel like you are needing to
manage the pain in a way that is
outside of your comfort zone
• if the patient and/or family members
are struggling with decision-making
relating to treatment options
• if there are multiple, simultaneous
distressing physical symptoms
In some instances, an interventional pain
management approach, or the resources of a
dedicated chronic pain clinic, might be most
appropriate, and that patient would benefit
from a referral to the pain management
specialist. If there is a broader total pain
phenomenon (having psychosocial,
spiritual, and quality-of-life elements
strongly impacting the physical pain
experience), the palliative care specialist’s
perspective may best complement the
hematologist’s ongoing care.
Continued on page 48
April 2015