Bringing difficult discussions to the forefront: encouraging timely patient – physician dialogue in palliative care 

PGY4 resident Dr. Amanda Caissie is no stranger to hard work. She completed her PhD in ocular oncology at McGill while attending medical school full-time at Queen’s. A native of the Maritimes, Dr. Caissie always imaged herself pursuing medical oncology, but it wasn’t long before a unique opportunity led her down a different path.

A recipient of the Ivan Smith Award in her second year of medical school, Dr. Caissie was first exposed to radiation oncology while participating in the four week program at the Odette Cancer Centre. The experience won her over: “Radiation Oncology is very different. The big difference for me is that it’s goal-oriented; you’re either aiming to cure or you’re aiming to palliate an actual symptom. It was the palliative component that really drew me in.”

Her interest in palliative radiation grew with clinical exposure where, over the span of one month during her clerkship years, she was able to see the remarkable benefits of non-curative radiation treatment: “As a medical student I saw that within one month a patient could come in miserable with bony pain, receive treatment, and leave with their pain controlled.”

Dr. Caissie’s passion for palliative care led her to seek out Dr. Camilla Zimmermann, Head of Palliative Care Services at the University Health Network, as a supervisor and collaborator. Her work with Dr. Zimmermann is focused on evaluating the policy and practice of ‘Do Not Resuscitate’ orders for patients with incurable cancer, and making recommendations where deficiencies exist. Timely DNR status discussions, those that occur within 24 to 48 hours of admission, are an essential component of palliative care. These conversations empower patients to make decisions about their care and similarly empower physicians to act according to the patients’ wishes without relying on substitute decision-makers in

dire situations. Dr. Caissie explains, “We’ve been able to show that if you don’t have the timely discussion, it leads to more ICU consults and futile CPR attempts. It’s not just hospital economics – it’s important for the patient and their families as well.” Dr. Caissie is keeping busy sharing her preliminary findings, recently giving an invited lecture at the Palliative Symptom Control meeting at the Temmy Latner Centre, a leading palliative care facility in Toronto. She also presented at the Ontario-wide Hospice and Palliative Care conference and the Annual Symposium of Multinational Association for Supportive Care in Cancer (MASCC) in Greece. Her palliative care research landed her the Best Resident Poster award last year at CARO, where she hopes to present additional work this fall.

She credits her supervisors for the support and opportunities she has received over the past couple of years. In addition to her code status research, Dr. Caissie has worked with Dr. Edward Chow on research specific to palliation in radiation oncology, and Drs. Shun Wong and Greg Czarnota on pre-clinical cancer research.

Looking to the future, Dr. Caissie expects her career to maintain an academic focus. “Through it all I want to maintain some kind of constant curiosity, be it on the research side of things or taking it into the clinical realm; to always ask ‘why?’”