TOH Chronic Ascites and Recurrent Effusion (CARE) Program

Previously the PleurX Program

TOH CARE Program staff above from left to right include: Karen Zappia CARE clinic clerk, Lorraine Cake, CARE clinic and Palliative Care nurse, Dr. Kayvan Amjadi, Medical Director of Interventional Pulmonology and Lynn Kachuik, Advanced Practice Nurse Palliative Care.

Management of malignant pleural effusions previously required repeated thoracentesis or inpatient admissions for chest tube insertion and pleurodesis, resulting in substantial morbidity. Repeated thoracentesis is resource intensive and provided only temporary symptom relief. Chest tube insertion and pleurodesis required a 16 day average length of stay at TOH. The Chronic Ascites and Recurrent Effusion or CARE Program (previously the Malignant Effusion or PleurX Program) began in May 2006 as an Ottawa pilot for outpatient management of malignant pleural effusions via the insertion and drainage of a specifically designed tunnelled catheter (PleurX).

The CARE program has evolved into a comprehensive LHIN-wide regional program encompassing both pleural effusion and ascites management. In addition, the Champlain Community Care Access Centre (CCAC) works collaboratively with the program to provide the required nursing care in the home setting, a critical factor in our program’s success.

The CARE Program has shifted the management of malignant pleural effusions to the outpatient setting. Patients are seen for an initial assessment and insertion visit followed by outpatient visits at 2 weeks and 6 weeks. The remainder of the patient’s care is provided in the home setting by specifically trained palliative care community nurses. The patients and community care providers have a single point of contact via phone and/or pager should problems arise. For this population of patients with an average life expectancy of approximately 3 to 6 months, the CARE program has significantly improved quality of life by providing rapid, effective symptom control, greater patient empowerment and reduced the need for hospitalization. The main measure of program success is in the shifting of care to the home setting for this palliative group of patients, allowing increased quality of life and increased access to enhanced symptom control and support in their last few months of life.

In 2009 the program expanded to include the use of the same tunnelled catheter to manage chronic ascites. In the oncology patient population, malignant ascites is a symptom that also portends a shortened life expectancy (3 – 6 months). Previous management at TOH entailed repeated large volume paracenteses to drain the accumulated fluid. Although this relieved symptoms, it provided only temporary relief with patients frequently undergoing multiple procedures and waiting until symptoms were severe before undergoing the procedure. Since the malignant effusion program had been successfully established, a pilot project using the PleurX catheter was initiated. The CARE program now encompasses both pleural effusions and ascites using the same processes with care provided in the home setting by CCAC.

The use of tunnelled catheters for the management of both pleural effusions and chronic ascites is now the standard of care across the Champlain LHIN. As of April 2011 the program has placed 867 pleural catheters and 282 abdominal catheters with a high success rate of reducing symptoms, low complication rates and very high patient satisfaction. TOH has the largest formal outpatient program in North America. We have shared our results locally, provincially, nationally and internationally via presentations and publications. As a leader in this clinical area we have mentored others to develop pleural effusion programs. There is now a program at Grand River Cancer Centre in Kitchener and we are working with clinicians in Toronto, Mississauga and Kingston to implement similar programs.

An evolution of the CARE Program model has resulted in the establishment of a Dyspnea Management Clinic for oncology patients with distressing shortness of breath. Established by this same group, this inter-professional clinic has seen over 70 patients in the past year. The clinicians provide comprehensive assessment of dyspnea to identify its underlying causes and provide individualized interventions to manage dyspnea and its effects on function, anxiety as well as quality of life. The Dyspnea Clinic is held each Monday afternoon in the Ages Cancer Assessment Clinic.

Referrals for both the CARE program and the Dyspnea Clinic can be called into the clinic clerk at (613) 737-8899 extension 79679 or the clinic nurse at extension 79987.

For more information on the CARE program please contact Lynn Kachuik, Advance Practice Nurse Palliative Care at lkachuik@toh.on.ca.