On this week’s episode of Cancer Care Connections, Cheryl Tan spoke with Dr. Scott Kruger, hematologist oncologist, and Dawn Quinn, palliative care program coordinator, for Virginia Oncology Associates. They cleared up the misconceptions about palliative care and how important it can be during your cancer journey. They also briefly discuss the differences between palliative care and hospice care, as well as the importance of having an advanced directive.
Dr. Scott Kruger is the medical director for Virginia Oncology Associates. He is board certified in Internal Medicine, Hematology, and Oncology. He is an Alpha Omega Alpha graduate of LaSalle University and Jefferson Medical School in Philadelphia, Pennsylvania. He then went on to serve in the United States Army where he completed his internship and Internal Medicine residency at Walter Reed Army Medical Center in Washington D.C. He completed his fellowship training in Hematology-Oncology at Letterman Army Medical Center and a visiting fellowship in bone marrow transplant at the Hutchinson Cancer Research Center.
Dr. Kruger has also been involved in clinical trials and research and has developed numerous presentations. Dr. Kruger is an active member on the Boards of the Leukemia & Lymphoma Society, US Oncology P&T committee where he serves as the chairman of the pharmacy subcommittee as well as the chairman for the Institutional Review Board for the Eastern Virginia Medical School.
Dawn Quinn is the Palliative Care Program Coordinator for Virginia Oncology Associates. She is CHPN certified by HPNA and ELNEC trained (End-of-Life Nursing Education Consortium) by the American Association of Colleges of Nursing. She has a BSN from Virginia Commonwealth University and MS in Palliative Care from the University of Maryland Baltimore.
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Resources mentioned in this podcast
Nation Hospice and Palliative Care Organization nhpco.org
Thank you for listening! If you're interested in hearing more from Virginia Oncology Associates, make sure to subscribe to Cancer Care Connections on Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.
Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com. or find us on Facebook or Instagram at Virginia Oncology Associates.
Episode 2: Palliative Care - Another Layer of Support with Dr. Scott Kruger and Dawn Quinn
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Welcome to Cancer Care Connections. On this episode, Cheryl Tan spoke with Dr. Scott Kruger, a hematologist oncologist, and Dawn Quinn, palliative care program coordinator, for Virginia Oncology Associates. They cleared up the misconceptions about palliative care and how important it can be during your cancer journey.
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Cheryl:
Our guests today are Dr. Scott Kruger and Dawn Quinn. Dr. Kruger is the medical director for Virginia Oncology Associates. Dawn is the palliative care coordinator for the Peninsula Area of Virginia Oncology Associates. And today we're talking about palliative care and what that means for families and cancer patients. Dr. Kruger, Dawn, thanks so much for joining us today.
00;00;26;02
Dr. Kruger/Dawn:
Thanks for having us. Thank you.
00;00;28;21
Dr. Kruger:
I want to start by getting an idea from both of you of what moved you into medicine and in particular, this part of medicine. So, Dr. Kruger, I just wanted to start with you. How did you get into medicine and why Oncology?
So what I love about medicine is the new science, the new treatments. When I got into medicine because my grandfather had multiple myeloma and they were kind of old country and my grandmother didn't want him to know that he had cancer. And of course, he knew. I remember I was about 16 years old and I was with him in the hospital and he said to me, "Do you think your grandmother knows that I know that I have cancer because that would upset her if she knew it. And I know these aren't heat treatments, it's really radiation therapy." I gave him a hug. I said, "We all know that you know, but it makes grandma feel better this way." So that's why I decided to go into oncology. It bugged me at age 16 that, you know, my family, we talked about the two patients, and my family members did not. And I just didn't understand why they just weren't honest with each other. I knew they loved each other. I knew they did everything they could for each other. But it was kind of strange that we had to talk around them. So that's one of the reasons I decided to go into oncology.
And I'll just tell you another brief story. When I was a third-year medical student, I was taking care of a very sweet lady and she was dying She had terminal cancer. And I stayed with her the whole night so she wouldn't be alone. And at first, I thought she was confused and she kept talking to me like I was her husband. And we reminisced about her entire life. And right before she died, she gave me a big hug and a kiss. And she said, "I want you to know all along, I know you that you're not my husband, you're just the med student. But for these 3 hours, you were my husband, and I got to relive my life, think about all the beauty, and for that, I thank you." And she died. And for men that was very moving.
00;02;42;02
Cheryl:
Yeah. Dr. Kruger, I love this opportunity to be able to hear stories like this and how much the time you have with patients means to you, and how it helps continue to push you forward. So thank you for sharing that. Dawn, what brought you into this particular line of work that you're in right now?
00;03;03;05
Dawn:
Well, I've been a nurse for well over four decades and have worked in intensive care and emergency room. I've taught. This led me to kind of understand, in addition to personal experiences, the experience of illness for everyone and how illness impacts the patient, but also the entire family. How each person walks their path hand in hand, but also separately.
It can be...it's life-changing. It's a life-changing experience. And so through all of the decades of practice, one thing led to another. I was teaching nursing and had a clinical group, and I saw a little ad in the paper, in the nursing journal for the VIPC program in which the Virginia legislature supports visiting an inpatient palliative care unit up at VCU.
And they sponsor you for two days to go up to learn about palliative care. And I thought, "That's great. I can go up there for two days and come back and teach my students more about palliative care." So it sort of was intriguing and early, early in the years of palliative care as it was starting to evolve and as soon as I was up there, I was up there in the unit paired with another nurse.
I was there for one hour, one hour, and they looked at me and said, "Well, you are a palliative nurse. Would you like to work here?" Because they recognized that I looked at the person as a wholeness, the wholeness of the person, not just focused on disease. And ended up working there for 11 years and had a wonderful experience understanding the relationships between the family members and the patients and how intimate our work is emotionally and how privileged we are to be invited into this private time in someone's life.
I eventually left that position to do some home hospice work, and then I segwayed into this position with Virginia Oncology, and it has been the most wonderful experience. I've been able to reestablish a palliative offering in conjunction with the oncology care the patient receives. And so when I sit with someone, I tell them, you know, "I am all about you as a whole person, not just focused on your cancer care. And I provide an extra layer of support for you. In addition to the fine care that you're receiving from your physician." And that is always so well received by people. People want to be seen more than a number or a diagnosis. They want to be seen in the entirety of their life. And I'm really privileged to be able to add that component and reinforce that component.
00;05;41;17
Cheryl:
I just have to say thank you to both of you for the work that you do. It is a comfort during what is a very difficult time for many people and their families. So I wanted to start by just defining what things are. You've talked about palliative care, and I think people can infer for those who are not in it already what that is. But can you just define what palliative care is for us in connection with and separately from the care that you will receive if you are a patient at Virginia Oncology Associates?
00;06;15;18
Dawn:
Do you want to take it?
Dr. Kruger:
Sure. I think everything we do is some degree of palliative care. We're treating the patient, we're treating their family, and we're treating their disease. When we do palliative care, our goal is to make the patient comfortable. We want them to be comfortable. We want them to be as happy as they can be. We want them to do the things they want to do in the time that they have left.
And so the goal of palliative care is to meet the patient and family goals and to make them happy. Sometimes that choice will be, we decide not to give you chemotherapy because the chemotherapy is having toxicities. It's not going to extend your life and it may be making you more sick and taking away quality. Sometimes it may be we give you medicine with it that's treating the cancer.
Sometimes it's just talking to you and finding out what you and your family want. And a lot of times it's letting the patient make the decision. I think sometimes people want the doctors to make the decisions. We can give you guidance, we can give you help, but I also want to know what you and your family want. What are your goals? What are your desires and how can we reach those?
Dawn:
And very often those change and so when you come into treatment early, you may have more of an idea of what you want, and that may evolve as time goes on. But I want to be sure that we understand that palliative care is not about death. It doesn't mean if you have a palliative care referral that the doctor knows something that you Dawn't know.
It means that we are just adding. We are sensitive to the quality of your life and we want to support you with really good symptom management. We want to support your head, your heart, your body, and your family. And it's an extra layer of support. Some folks are worried that it means that one is dying and that's not always the case.
Many people receive palliative care and go on to live a very long life. Palliative care can be given if you have congestive heart failure, if you have arthritis. I mean palliative care can be integrated into any discipline as an extra layer of care. But the idea is to protect the quality of life and look at you in terms of the entirety of your family.
00;08;23;18
Cheryl:
Dawn: I'm so glad you addressed that because it's one of the questions that I had. If I'm looking at it correctly and thinking about it in the way that you're talking about it, it is kind of like the umbrella. It's kind of like umbrella care. And maybe that's not the right way to describe it, but that's how I'm thinking about it in my head, that it is just care that is extended to patients.
That helps you think a little bit differently about your treatment, no matter what that treatment is. So I want to get a little clear, a little more clear about palliative care at Virginia Oncology Associates. So in terms of how does one get one? Does it make home visits? Is it different from hospice? So could you kind of really talk about some of the logistics of this type of care here at Virginia Oncology Associates?
00;09;14;11
Dr. Kruger
Palliative care starts when you have extra needs to keep you comfortable and after you have extra needs, we meet those needs and the best we can. So that may be nursing from VOA, our practice. It may mean setting you up with home care. It might mean sending a physical therapist out there. It might mean, and it usually does mean a social worker to help you with your finances, helping with maybe getting extra aids at home, helping you with transportation, helping you with the cost of care and the cost of drugs.
Drugs are very expensive. How do you get it if you're on a fixed income? As we move on, as patients have usually a terminal disease when it's estimated but not definite, when it's estimated that their survival may be six months or less than hospice may be in addition to palliative care. Hospice is usually a Medicare program. It's the same with any insurance. There's no charge for it, there are no co-pays, and a doctor certifies that they guess that your survival is less than six months and that you're going to need extra help and extra care during that time period. And then hospice will also add to palliative care, come make visits to your home. Sometimes your doctor will make visits, your nurses will make visits.
You'll have a social worker, you'll have a chaplain. We just increase the amount of services, with the goal being to improve your quality and your length of life. Many, many people pass the six-month mark. Many people pass the one-year mark, but it's based on what your needs are. So it's adding care without really adding expense.
Dawn:
And there's a little distinction between palliative care and hospice care in that when you receive palliative care through Virginia Oncology, you are actively seeking treatment.
You are still receiving treatment, and our palliative care is concurrent with that treatment, and so you continue to treat your disease. Hospice care is recommended when you no longer desire the treatment, you're no longer tolerating the treatment. The physician just doesn't recommend that it's advisable to continue treatment. And so when treatment is no longer being given, then hospice care is so appropriate because it is a plan of care. It is about living, it is about quality of life, and the plan of care shifts from disease treatment to disease management and symptom control and quality of life purely for comfort and to maintain your quality of life. And very often when you enroll in hospice early, your life is actually..there are lots of studies that support that your life span is actually extended because your symptoms are controlled and you are not suffering and you are able to enjoy your life in a way that you weren't able to before. So it is quite nice.
I receive referrals from physicians, APPs, our nurse practitioners, our physician assistants, bedside..chair side nurses will identify somebody who might have a palliative need. We talk among ourselves and if the physician agrees, we...a referral is placed for palliative care. And then I contact the family of the patient and we get going with our relationship.
And those of us here at VOA work with many different hospice agencies. Who you choose is your personal choice. Sometimes it may be based on your insurance, but we work with all companies and all people. We also understand that every company does things a little differently and we might be able to guide you on which one may meet your needs better. Some are more religious than others.
Some are less religious. Some may, because of their location, be able to reach your home closer, and faster. So it depends on what your needs are and we help guide you on which company you might want to choose, and all of them will come up to your home. You can interview one company, two companies, or four, and you can choose whichever one you want. We will work with you.
Dawn:
And part of my role is to help families work through that transition of care from active treatment to comfort. And sometimes that's a long emotional journey for the patient or the family members, and people may be on different pages and it takes a little while to reconcile that. I'm able to spend lots of time talking through issues and answering questions and readdressing things in whatever amount of time is required by that family and patient as opposed to a short office visit.
So I can continue the conversation until everybody is..until everybody's in a good place and there's a smooth transition of care. I can provide lots of detailed information about hospice care so that when they hear it again, they've already heard some and they hear all of it. It really helps in the transition enormously.
00;13;55;27
Cheryl:
I imagine having a conversation with someone like you is so comforting in a time that is so foreign. I wanted to ask you what the message is to patients and their families. How can they best, I don't know if the right word is navigate, but how can they best understand the best way to get the best care, knowing that these options are available to them?
And scary as it is, there are people like you, Dawn, that walk them through, and it sounds like hold their hand.
00;14;30;26
Dr. Kruger:
We're very fortunate to have Dawn with us. I would say the most important thing, a patient should do is ask questions. Sit down with your care team, let us know what's going on. Let us know what your concerns are. What are you worried about? What do you see at home that maybe we don't see when you're in our office, and let's address the whole person? Let's address what your concerns are, what you're afraid of? What do you think the patient's afraid of? What are their needs at home? What are the things you're having trouble with? And then we'll work something out.
Dawn:
I echo that. I hear so many people trying to be polite or respectful of the physician because they're busy, not wanting to bother someone, and just to remember that we care very, very much about your concerns.
And it's very upsetting to hear that someone has been sitting at home waiting for their appointment in three weeks when they've been suffering already for two weeks. And it's not anything that we want. So we invite open communication, we invite calling, we invite extra appointments if necessary. If anything changes, let us know and we'll take it from there.
Dr. Kruger
We have a long relationship together with our patients and their families. Many of these people we've known for ten years or more. So honestly, you become a part of our families too, and our nursing staff and our front desk staff, and we want to help you. We don't think that's bothering us. You know, we have the tools and the knowledge of the things that are available, and sometimes we don't know what you need until you tell us.
So don't be afraid to ask us anything. Be totally honest, let us know because you'd be surprised by some of the things we can work out, we can be very creative.
00;16;17;18
Cheryl:
Yeah, and very proactive. And I and I love what you just said about really furthering that relationship because when you have a real relationship with someone, you tell them like it is. You say what's on your mind and it sounds like that's what you're interested in, in really getting to the root of a problem or an issue in order to find a solution as much as you're able to do so.
So I wanted to ask just more logistically, once again, does it, what should a patient have in a sense, in preparation? Like would it be helpful for them to have an advanced directive? Would it be helpful if they had certain things? What can we help them do to set themselves up for as much success as possible? Going through a very difficult time?
00;17;05;15
Dr. Kruger
Well, there's a lot of confusion about what is an advanced directive. An advance directive is once you know your disease process and you're able to make decisions, it's a patient's choice of what is it that they want and they make that choice in conjunction with their families. Your doctor and your nurse will give you a lot of guidance.
So, for example, will putting you on a breathing machine, make you live longer and help your quality of life. Well, that depends on whether it's something that's temporary and can be fixed or something that can't be fixed. And we have those conversations with people and they make the decision as to what they want. The reason to write it down is so that everyone in the family knows that it's your decision and this is what you want.
The worst thing that can happen is you've never had that conversation with your loved ones and everyone wants to make a decision of something that's different and no one knows for sure it's what the patient wants. So it's really about communication. If you have a do not resuscitate and you're in the hospital, I might say to you, you know, this is pneumonia, seven to ten days of antibiotics would get better. Maybe you want to do the support if you need it. And so there's a lot of discussion and things change. And it's important that the patient has the right and the knowledge to tell them the truth. First of all, We make sure the patient understands their disease as well as their family so that they can make decisions.
And those decisions are important for families. So the reason we have you write it down is it's important that everyone knows this is what "I want, I'm a sick patient."
Dawn:
It's actually a very important gift to give to your family. If you become unconscious and can't speak for yourself and the family doesn't know what you want, it puts them in a terrible position of decision making and they're not sure what to do.
And they usually opt for everything, when maybe that is not at all what you would like or at all what you can tolerate. And so it's really, really a gift of love. And it settles the debate among different members of the family if you can just focus on what the person themselves wants for themselves. And if we focus on what each individual desires their preferences are, that helps the dynamics and the family tremendously.
The last thing you want is there to be contention among family members because everybody's guessing about what you want when you can simply solve that by declaring what your wishes are
Dr. Kruger:
You know, advanced directives are not just for the sick, it's for the healthy. Just like we have to write a will. You know, it's letting your family know what your wishes are, what your beliefs are, what your morals are, and people can change their minds and there's no problem with that.
Well, I know when I first got married, I did an advanced directive. I thought if God forbid, something happens, it's clear what my wife wants. It's clear what I want. And we can change that based on what's happening medically or clinically. But it's really just like saying I'm willing to take antibiotics or I'm willing to do a blood transfusion or I'm a Jehovah's Witness I don't want a blood transfusion. It's really making your choices.
Dawn:
And important to identify who you trust the most, to defend your desires and wishes, who will be able to put aside their personal feelings and support what you want. And that person will be your designated decision-maker.
00;20;38;25
Cheryl:
Dawn, Dr. Krug...,[interruption] Sorry, I apologize for that.
00;20;42;04
Dawn:
That person you identify in your advanced directive.
00;20;45;28
Cheryl:
Dawn. Dr. Kruger, thank you so much for your time, for sharing your heart, and for helping patients and their families learn how they can communicate best with the people who want the best in their medical care. Are there any takeaways you'd like to share before we wrap up this session?
00;21;05;15
Dr. Kruger
I would say don't be afraid to have the conversation. Doctor's offices are busy. Families are busy. Sit down and say, maybe I need a little extra time. Schedule it if you can and let's just talk about what's happening and what's going on and let us know how we can help you. Let us know the problems you're having at home. Let us know you can't afford groceries. Let us know there are transportation issues. We can help with that.
Dawn:
And I would say live your life remembering what's most important to you every day.
00;21;36;04
Cheryl:
To both of you, thank you so much for your time. And I know there are resources for people to access. Where's the best way for them to get that information if they want to do a little online homework before reaching out and having that conversation?
00;21;53;21
Dr. Kruger:
There's the National Hospice website. So that's actually very helpful. They give you information in terms of what hospice is and what they do in terms of palliative care. You could just do a Google search of palliative care. They give you a lot of good information. What resources are there in your area? You might contact some articles about what palliative care does.
There's information about what's a good pain medicine. There's information about vitamins, minerals, healthy diet, exercise, all those other things that can help you, and where you can reach out in your local area to get more information.
00;22;30;27
Cheryl:
Thank you both for your time and we appreciate the care and attention you provide your patients and their families. Thanks so much for joining us today.
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That’s all for this episode of Cancer Care Connections. Stay tuned for our next episode where Cheryl will be speaking with Dr. Gary Simmons about CAR T-Cell therapy.
Don’t forget to subscribe to our podcast via Apple Podcast, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.
Virginia Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information visit us at virginiacancer.com or find us on Facebook or Instagram at Virgina Oncology Associates.
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