Practice Recommendations of Patient-Centered Tele-Palliative Care

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1		Akhila Reddy	--	2181	2023-04-13 14:59:12	\|
2	format	Jason Zhu	Meta information modification	2181	2023-04-14 03:44:04	\|

This entry is adapted from the peer-reviewed paper 10.3390/cancers15061809

Cancer patients receiving palliative care may face significant challenges in attending outpatient appointments. Patients on controlled substances such as opioids require frequent visits and often rely on assistive devices and/or a caregiver to accompany them to these visits. In addition, pain, fatigue, and shortness of breath may magnify the challenges associated with in-person visits. The rapid adoption of telemedicine in response to the COVID-19 pandemic has proven to be highly beneficial for advanced cancer patients and caregivers. The hurried COVID-19-related implementation of telemedicine is now evolving into a permanent platform for providing palliative care.

telemedicine palliative care cancer best practices

1. The Pre-Visit Checklist

Researchers recommend completing a checklist of items 1–2 days before the telemedicine visit. This can be performed by office staff or medical assistants before the visit. Following this checklist ensures that patients and their caregivers are adequately prepared for their visit. The pre-visit checklist should attempt to:

Confirm the appointment and access to the internet and audio-video platform used during the visit.
Check the patient or caregiver’s familiarity with the audio-video platform and offer assistance with downloading applications and registration.
Ask the patient to log in 1-hour ahead of the appointment to ensure there are no challenges and provide ample time to seek assistance.
Provide a contact for troubleshooting or a help desk if the connection is unsuccessful on the day of the visit. Access to a help desk is crucial, and centers should invest in a capable support system for the success of any telemedicine program.
Confirm the patient’s intended location to ensure telemedicine is permitted in their geographical area. For example, many states in the U.S. do not allow telemedicine visits across state lines. The patient’s address and call back number during the visit can be helpful in emergencies or if a patient expresses suicidal or homicidal ideations.
Identify if an interpreter service is required and make arrangements for an interpreter to assist in the conversations and join the telemedicine visit.
Encourage the completion of assessments before the visit, such as the Edmonton Symptom Assessment System (ESAS) and other screening tools.
Stress the importance of having a private space and dedicated time for the visit.
Encourage the use of headphones if private space is not accessible.
Encourage family participation, including those in various locations, and offer access to the help desk as needed.
Walk them through the anticipated workflow that can be expected during the visit.

2. Patient Setting

Tele-palliative care allows the patient to experience personalized care in an environment that is familiar, which may add to the therapeutic relationship between provider and patient. Cox et al. highlight how patients who meet with physicians electronically in their homes perceive increased time spent, given that they can meet in a comfortable and familiar environment (their homes) ^[1]. Although patients should feel comfortable in their environment during the meeting, they should also be in a location and setting that allows them to give their full attention to the video visit. The providers should encourage patients to be in a well-lit room with a functioning camera on their phones or computers. They should promote safety and recommend that patients schedule their meetings far from distractions such as watching young children. Visits should be halted if safety is questioned, such as if a patient is driving during the tele-visit ^[2]. Providers should also encourage the patient or caregivers to move the camera or change positions to visualize the patient’s entire face and torso. Proper positioning will help ensure the patient and provider are giving the visit the attention required for a good therapeutic outcome. The same setting recommendations apply to family members not present with the patient and joining the visit separately. If the patients or families cannot participate in the tele-visit from a private location, headphones are strongly encouraged.

3. Palliative Care Provider Setting

Proper positioning is also essential for the provider for a successful video visit. Strasser et al. studied the importance of sitting vs. standing during oncology visits. They found that patients strongly preferred and perceived better care was provided by physicians who sat rather than stood during the visit ^[3]^[4]. It is recommended that the provider sit comfortably without distractions, be relaxed, face the camera to make adequate eye contact, and lean forward a little to convey attentiveness. Providers should move the patient’s image near the camera if the video platform allows, to enable easy eye contact. It is also crucial that the provider is in a quiet, well-lit room during the video visit, with a professional background or one that conveys a peaceful and relaxed atmosphere without any bright or flashy distractions. Avoid windows or bright lights in the background. The presence of other members of the team or staff within the video frame is discouraged.

4. Acquainting the Patient

First and foremost, verify that the patient can see and hear you. Introduce yourself and identify the patient using the institutional guidelines, for example, the name and date of birth. Once the patient’s and family’s identity (if present) are established, greet them warmly and go over what to expect during the visit. Establish a rapport early and assure them of privacy. The patients must have a sense of privacy and feel secure in their conversations with the provider. Acknowledge the limitations of the video visit and include that platforms allow only one person to speak at a time. Minimize interruptions and rely more on non-verbal responses such as nodding your head, raising your eyebrows to express concern, or leaning forwards rather than saying “hmm” or “yes” or “I know” while the patient is speaking, with an emphasis on webside manner ^[5]^[6].

Avoid eating or drinking during the visit and mute all potential distractions such as pagers, cell phones, and emails. Identify a backup plan early in the visit if there is a loss of internet connection or poor-quality audio. Prioritize listening over speaking and avoid long pauses. Focus on non-verbal means to convey empathy and respond to emotions. Avoid taking notes or working on the patient’s chart during the tele-visit. Periodically summarize your understanding of the patient’s discussion to ensure you both are on the same page. Use verbal responses such as “I wish.” and “I admire.” to convey empathy.

Telemedicine has limitations, and those must be clearly explained to the patient. For example, one cannot conduct a thorough physical examination that may be necessary for an accurate diagnosis ^[7]. It is essential to clarify the achievable goals regarding patient care at the onset of the meeting to ensure the nature of the tele-visit is understood. While the pre-visit checklist helps acquaint the patient with the nature of the visit to a certain extent, an additional moment to reacquaint the patient is recommended. Introducing the nature and goals of the visit at the onset helps remind the patient and any caregivers present that medical providers will take their concerns seriously and address them similarly to an in-person visit ^[8].

5. Assessments and IDT Visits

It is crucial to maintain a consistent workflow for the IDT during tele-visits and match the workflow to in-person visits ^[9]. At MD Anderson Cancer Center, the tele-palliative care workflow begins with the patient checking into a virtual waiting room environment where the registered nurse (RN) obtains a brief medical history, clarifies the reason for the visit, conducts a comprehensive symptom assessment using the ESAS as a guide, and updates the medication list in the chart. Assessments such as the Memorial Delirium Assessment Scale (MDAS), the Cut-down, Annoyed, Guilty, and Eye-opener questionnaire (CAGE), and the Eastern Cooperative Oncology Group Performance Status Scale (ECOG) can also be performed at this time. Subsequently, the nurse places the patient in the virtual waiting room and presents the report to the physician or the APP. The physician or APP then joins the video platform and proceeds with the rest of the tele-visit, expanding on data gathered during the RN assessment. Following the physician’s assessment, other interdisciplinary team members, such as the pharmacist, chaplain, counselor, nutritionist, social worker, or case manager, are invited to join the visit as needed. To replicate an in-person interdisciplinary palliative care visit, members of the IDT must be available to join the visit as needed. The provider may leave and join later to close the visit (see #7) ^[10]. This allows for real-time interventions to address patient needs and provide personalized care. Having the virtual involvement of the IDT frees the patient and the IDT from some of the constraints that time and distance may put on interdisciplinary intervention and helps ensure that patients receive evaluation and input from many team members simultaneously.

6. Physical Examination in Telemedicine

A proper physical exam can aid physicians in diagnosing and treating patients. Whether virtual or in-person, the findings of a physical exam can go a long way toward accurately diagnosing and helping patients by providing adequate pharmacological and psychological support. Moreover, advanced cancer patients indicate that examination is a highly positive aspect of their care ^[11]. In the context of a tele-visit, conducting such an exam becomes more complex through the camera’s lens. Overcoming the barrier to examining a patient via video may be possible by having a keen sense of observation and learning to perform a visual examination. Various assessments and screening tools can be used as part of the video visit with subtle modifications to enhance the virtual examination of a patient.

Providers should always ask themselves, "does the patient look uncomfortable?" Consider requesting the caregiver to check vital signs if possible since some patients possess blood pressure cuffs, pulse oximeters, etc.

You can evaluate the size of pupils, which could be particularly useful when there is a concern for non-medical opioid use (NMOU). If there is doubt that the patient may be using recreational drugs, look for mydriasis (benzodiazepines, stimulants, cannabis, or alcohol) or miosis (opiates) ^[12]. Invite the patient to move closer to the camera to glimpse the gums, oral mucosa, and throat. Check the tongue movement, especially in head and neck cancer patients and those with mucositis.

Through a video visit, a physician could also assess for respiratory distress, observing closely for the use of accessory muscles or even audible wheezing or cough. Consider evaluating respiratory effort using the Roth score: request the patient to take a deep breath followed by counting out loud from 1 to 30. If the maximal counting number is <10 or the counting time is <7 s, then the pulse oximeter reading is likely less than 95%. If the maximal counting number is <7 or the counting time is <5 s, then the pulse oximeter reading is likely <90% ^[13].

Observe carefully for any abdominal distention, protruding masses, or possible ascites. Palliative care patients are particularly affected by bowel problems ^[14], mainly related to the use of opioids, metabolic disturbances, reduced oral intake, poor performance status, tumor burden, or metastasis. Besides obtaining important information such as the timing of the last bowel movement, an abdominal exam assisted by the patient or family members can help you determine if the abdomen is soft, tender, or rigid and whether the findings need further in-person evaluation.

Observe the extremities for myoclonus, swelling, and erythema. Patients receiving opioids must be observed for signs of neurotoxicity (confusion, drowsiness, myoclonus). An MDAS can also aid in a neurological evaluation. A psychiatric evaluation by assessing mood, affect, psychomotor agitation or retardation, euphoria, anxiety, anhedonia, and suicidal ideation is essential.

7. Closing the Visit

Along with summarizing the visit and ensuring that the patient and family are agreeable to the proposed treatment plan, an opportunity must be provided for the patient to discuss any last-minute concerns. After completing the tele-visit, the physician can place pertinent orders, send electronic prescriptions to the pharmacy, order any testing, and schedule the next visit. The follow-up visit could be a tele-visit or in-person based on the patient’s needs and the provider’s assessment. Telemedicine can promote continuity of care as many patients may find it feasible to attend follow-up telemedicine visits compared to in-person visits ^[15]. Patients exhibiting NMOU behaviors or symptom distress that need a thorough physical exam can be scheduled for a short-term in-person follow-up appointment. Palliative care clinics offering telemedicine visits must have guidelines set forth to care for patients with NMOU, and follow-ups must be scheduled accordingly ^[16]. These patients may need random urine drug screens as part of their treatment plan.

Providers can also make arrangements for patients to complete advance directives such as medical power of attorney, living will, and out-of-hospital do not resuscitate documents. Many of these documents can be completed electronically with assistance from the IDT, and such services must be offered to patients who otherwise cannot come in person. Finally, the provider must assess the patient and caregiver’s comfort with the virtual format and ability to participate successfully in future telemedicine visits. If patients are uncomfortable with participating or unable to participate adequately in telemedicine visits, in-person appointments must be offered. The patient’s comfort with technology, cognitive abilities, and safety barriers, such as driving or engaging in other activities during the visit, must be considered before scheduling a follow-up visit (telemedicine vs. in-person).

References

Cox, A.; Lucas, G.; Marcu, A.; Piano, M.; Grosvenor, W.; Mold, F.; Maguire, R.; Ream, E. Cancer Survivors’ Experience With Telehealth: A Systematic Review and Thematic Synthesis. J. Med. Internet. Res. 2017, 19, e11.
Agosta, M.T.; Shih, K.K.; Vidal, M.; Zhukovsky, D.; Bruera, E. Patient behaviors during virtual clinic encounters in palliative care. Palliat. Support. Care 2022, 21, 178–180.
Strasser, F.; Palmer, J.L.; Willey, J.; Shen, L.; Shin, K.; Sivesind, D.; Beale, E.; Bruera, E. Impact of physician sitting versus standing during inpatient oncology consultations: Patients’ preference and perception of compassion and duration. A randomized controlled trial. J. Pain Symptom Manag. 2005, 29, 489–497.
Bruera, E.; Palmer, J.L.; Pace, E.; Zhang, K.; Willey, J.; Strasser, F.; Bennett, M.I. A randomized, controlled trial of physician postures when breaking bad news to cancer patients. Palliat. Med. 2007, 21, 501–505.
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Reddy, A.; Arthur, J.; Dalal, S.; Hui, D.; Subbiah, I.; Wu, J.; Anderson, A.E.; Castro, D.; Joy, M.; Nweke, C.; et al. Rapid Transition to Virtual Care during the COVID-19 Epidemic: Experience of a Supportive Care Clinic at a Tertiary Care Cancer Center. J. Palliat. Med. 2021, 24, 1467–1473.
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Update Date: 14 Apr 2023

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