When Worlds Collide: A Multidisciplinary Model for Complex Care (CS371)

• Published in: Journal of pain and symptom management 2023-05, Vol.65 (5), p.e576-e576
• Main Authors: Vipler, Erin, Treem, Jonathan
• Format: Article
• Language: English
• ISSN: 0885-3924
• DOI: 10.1016/j.jpainsymman.2023.02.133

1. Understand how coexisting psychiatric and medical diagnoses can create challenges to providing care. 2. Describe a multidisciplinary, patient-centered approach to complex care management. Patients with malignancy, psychiatric comorbidities, and substance use disorders present clinical challenges in care when suffering with pain. We present a harm-reducing home care model for a patient with metastatic breast cancer, a decades-long opiate use disorder, and severe obsessive-compulsive disorder (OCD) with agoraphobia. The key to this model is the close collaboration between home nursing, palliative care, psychiatry, and addiction medicine. A 55-year-old female with breast cancer metastatic to multiple axial skeletal sites including a pathologic fracture of the pelvis with nonunion is referred to outpatient palliative care for malignant pain management. She has a 20-year history of opiate-use disorder and polysubstance misuse and overdose, primarily CNS depressants including gabapentinoids, benzodiazepines, and muscle relaxants. She has a lifelong history of severe OCD with agoraphobia including a recent hospitalization for bleach-induced pneumonitis and antimicrobial surface cleaner toxic ingestion. A collaborative care model is established between her oncology team, addiction medicine, palliative care, and psychiatry with palliative care acting as the primary team. As the patient's agoraphobia limits clinic visits, a home care nurse team establishes an acceptable home visitation strategy with the patient. Using the home nurse team as the eyes and ears of patient visits, the multidisciplinary team enacts balanced treatment strategies that balance the patient's quality of life, risk of self-harm, and medical goals. In the first 6 months of implementation, the patient is not seen in the hospital for intentional or unintentional overdose, psychiatric complications, or pain and feels her care is well managed and in line with her goals and values. This case presents a high-resource solution to a well-described problem in modern palliative care: care of a patient with co-occurring malignant pain and substance use disorder with psychiatric comorbidities. We describe a home-based care option dependent on careful and thorough multispecialty collaboration.