Transcription:
Palliative Care: Helping a Wide Range of Patients

Melanie Cole (Host):  Many people associate palliative care with end of life care but it can help a much wider array of patients. My guest today is Dr. Leslie Blackhall. She is board certified in internal medicine along with hospice and palliative medicine at UVA Health System. Welcome to the show, Dr. Blackhall. I’d like to ask you to begin by describing what palliative care is and what it’s designed to do.  

Dr. Leslie Blackhall (Guest):   Thanks so much for having me. I think, in a way, the best way that I can use to tell you what palliative care is, is to describe what I do. I work, along with my colleagues here at University of Virginia, with people with serious illnesses like cancer, heart disease, emphysema, and help improve their quality of life. To give you an example, I work in the cancer center – this is one of the places I work – with patients with cancer at any stage of illness, including those who have been cured of their cancer, are undergoing curative therapy, or those who have more advanced and serious cancers. I work with them to help them with pain control, control of symptoms related to the cancer, but also side effects of the treatment, like nerve damage in the feet, fatigue, nausea. We work together alongside the oncologists to help patients tolerate their treatments better or to help them get their lives back after they’ve completed treatment or, in people who have incurable cancer but may live for very long with those cancers, as people do now. We help them be as functional as possible and to have as normal a life as possible. I think, in general, that is the goal of palliative care to work with people who have serious illnesses; to work alongside their doctors who treat those illnesses and help improve their function, their quality of life and their ability to lead as normal a life as possible with their illnesses.

Melanie:  People hear the word “hospice” and their hear “palliative” and they think they are the same thing and that if someone is involved in palliative care – and as you have explained – but that it means that they are now near the end of their life.  Please, explain the difference.  

Dr. Blackhall: I think that, actually, the most accurate way to think about hospice is as an insurance benefit that provides certain types of care for people in the last months of life. To be eligible for hospice, you have to have six months to live. In general, most people are on hospice for a much shorter period of time usually because there is no further treatment for, say, their cancer or their heart disease and their goal is to remain at home and have their symptoms treated. I see patients for years and years, some of whom have been cured of their cancer. While both hospice and palliative care focus on symptom management and improving quality of life for patients, palliative care doesn’t have the restrictions of short life expectancy or that the patient has given up treatment for their cancer or heart disease or whatever it is. I do take care of patients on hospice but that is a small percentage of actually what I do.  

Melanie:  If someone is involved in palliative care, can they continue treatment, too? As you say, they can be cured of their cancer or in remission and still get palliative care. Some people are afraid that if they sign up for palliative care, it means that they are no longer going to be treated by their doctor and no longer are going to be able to get restorative care.

Dr. Blackhall:  That’s a great question and absolutely if patients sign up to see me, they don’t need to give up any other type of care. In fact, the oncologists I work with consult with me in the hope that I will work alongside with them and help their patient tolerate their treatment better. For example, people getting radiation for an illness like head and neck cancer, it can be a very hard treatment to tolerate. It causes problems with swallowing, with pain in the neck and depending on the type of treatment, nerve damage in their feet or severe fatigue. Some of those people need to undergo therapy for seven weeks. They wouldn’t make it through their treatment unless we worked alongside of our oncologic colleagues to help them tolerate the treatment well enough by controlling their pain, by helping them with problems eating, by working with other professionals like dieticians and social workers and things like that to help people continue to tolerate the treatments that may even cure them. Once they have completed that treatment, there are often some lingering side effects that people need help with. I see our job is to work that side of the aisle while freeing up the oncologist’s time to focus on disease-specific treatments for the cancer itself.

Melanie:   When we speak of palliative care, what does that even mean as far as actual treatments, Dr. Blackhall? Are we talking about psychological support and nutritional advice and dietary information, medication, pain management? Explain really what it means.

Dr. Blackhall:  I would say all of the above. Whether I see the patient in the hospital or in the clinic, over in cardiology or in the cancer center, one of the questions I often ask people is, “What is it that you are having trouble doing that’s important to you in your life and what’s making it difficult for you to do that?” Sometimes the treatment people are undergoing is making them so fatigued that they can’t get out of bed, hardly, and that’s making them depressed. They can’t enjoy their time. We focus on sort of a holistic assessment of is it the chemotherapy, is it an anemia, is it some sleep disorder or some other problem? The treatments might include referrals to physical therapy, medications to help with sleep, or other medications to improve focus and concentration. Sometimes people have become very depressed or anxious and then I’ll work with a psychologist and the social workers and people like that and occasionally prescribe medication. Often it is pain. People with cancer or heart disease or other serious illnesses often suffer quite a lot of pain, either as a result of the treatments or because of the underlying disease itself. Then, our job is to be really good at trying to treat people’s pain without making them have a lot of side effects from treatment and without having those medications interfere with their other drug interactions or interactions with the treatment of whatever their underlying disease is. People may be having trouble eating, either with their appetite or they are nauseated or whatever, to try to determine what the underlying cause of the nausea is and then treat that effectively. I would say that is our focus. I always say that the oncologist is looking at the tumor and how to shrink it. Obviously, my oncologic colleagues care very much about the whole patient but my job is to look at the patient and their symptoms in the same way that maybe the oncologist looks at the CT Scan or the cardiologist looks at the cardiac ultrasound and try to look at what are the things that are keeping people from actually leading their lives? People nowadays live very long lives despite having chronic illnesses but what we focus on is trying to make sure they can really live those lives; that those lives are full of what they want to do so that they are not sort of stuck at home suffering from so many symptoms that they can’t enjoy the time that medical treatments are bringing them.

Melanie:  Wow. How beautifully put. I applaud all of the great work that you do, Dr. Blackhall. UVA was recently named one of eleven palliative care leadership centers. Can you just tell us what that means?

Dr. Blackhall:  Yes. We were named a palliative care leadership center because of our work in outpatient palliative care, meaning in the clinic setting. In the past, a lot of palliative care has been done when people are in crisis in the hospital. So, the cancer patient who comes in with pain completely out of control or the heart patient who is having trouble breathing and having a lot of life problems related to their heart failure or the emphysema patient who chronically is having trouble managing at home. The problem is, once people get discharged how do we continue to follow them up? Or, even more importantly, how do we work with these patients before they end up in the hospital to prevent them from having to go to the E.R. where nobody wants to go – let’s face it – to get treatment. Here at UVA, in fact when I came in 2001, we started an outpatient clinic in the cancer center. It was one of the earlier ones. We now have one of the larger outpatient programs which we have had many grants and awards to expand. What it means for us to be a national palliative care leadership center is that other programs that wish to develop similar projects will be coming to us or one of the other eleven sites to be trained in how to do this.

Melanie:  That is absolutely fascisnating. Thank you so much for being with us. What great information. You’re listening to UVA Health Systems Radio and for more information you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.