At the point a patient with advanced lung disease is considered for transplant, he or she is severely ill. While all transplants are challenging, patients who undergo lung transplant can face a particularly rough road. To gain a more in-depth understanding of the patient under consideration, Baylor University Medical Center at Dallas (Baylor Dallas), part of Baylor Scott & White Health, has embedded supportive palliative care into the lung transplant program.
“Our goal is to try to save the patient’s life, and hopefully, give them many more years of life,” says Todd Grazia, MD, chief of transplant pulmonology at Baylor Dallas. “But lung transplant carries a great deal of risk. Supportive palliative care can get more detail during the evaluation process. They delve into the patient’s goals and values, their thought processes and what is important to them. They learn what the patient would want or not want if things don’t go well. The supportive palliative care team provides another layer of knowledge to help us take care of our patients.”
The multidisciplinary supportive palliative team includes six physicians, five advanced practice providers, two social workers, two full-time chaplains and two child life specialists who work with the children or grandchildren of patients in the hospital. The team provides up to 20 consults per day.
Historically, the primary involvement of supportive palliative care has been with patients where transplant was not an option and the symptom burden was high. The team would help the patient navigate the steps ahead, such as wishes for end-of-life care. For patients with lung transplant as an option, the approach is focused more on preparedness planning.
“We explore the patient’s quality of life, desires, fears and hopes, blending all of that with the proposed treatment regimen collectively so that the patient, family and treatment team are all on the same page,” says Mark A. Casanova, MD, FAAHPM, director of clinical ethics and supportive palliative care at Baylor Dallas. “We see the individual and family unit through different lenses than the transplant team. Are there concerns that are more likely to make the transplant journey a successful one? With transplant, if there is not the desire to fight with every ounce of your soul to make it successful, it may give us pause. Once in a while, a patient may have an unusual value system that doesn’t align well with transplant. At that point, we can transition smoothly into a different goal of care.”
Dr. Casanova describes his team’s role as that of a neutral third party with the skill set of exploring delicate and difficult situations. The supportive palliative care team is not involved in the management of the patient or the decision about whether a patient is a candidate for transplant or not. Experience has shown that having a third-party physician or advanced practice provider guide the conversation with patients results in a more in-depth and valuable perspective.
In addition to providing key information during the evaluation process, the plan is to keep supportive palliative care involved at the time of transplant, as well as post transplant. Because lungs are exposed to the outside environment through respiration, they are more prone to infections and, consequently, rejection.
“With lung transplant, at some point, a patient is going to develop chronic rejection,” Dr. Grazia says. “We hope that it’s 10 or 20 years down the road, but it will occur at some point. When an immunosuppressed patient gets an infection, it is likely to be in the actual organ transplanted, and infection in the lung can trigger rejection. We want to offer patients the broadest range of care available, and that means incorporating supportive palliative care from the very beginning of their transplant journey to the time they inevitably develop symptoms of rejection.”
Supportive palliative care consultation is available upon request of the attending physician, although inpatients or their family members may request an informational visit from a supportive palliative care team member. For service at Baylor University Medical Center, please call 214.820.9248, Monday-Friday, 9:00 AM – 4:00 PM.
