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 patients 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 physician 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 traditionally have had limited contact with palliative-care services. As an embedded service, we participate in interdisciplinary 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 endured long admissions for induction therapy on our leukemia unit, are in remission and (hopefully) finally feeling well again, and are now willingly submitting to the transplant process, despite the risks.
For many patients with a hematologic malignancy, BMT is the treatment 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 conversations about what to expect from treatment, 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 experience (including certification as an advanced practice hospice and palliative 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 questions like how to provide care that will give patients the best chance of survival while preserving their quality 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.