What is best practice for documenting and communicating the treatment plan?

From Cancer Guidelines Wiki

Introduction

The treatment plan is a documented record of all major aspects of individual patients planned cancer therapy and is an essential reference and communication resource for the patient and all healthcare professionals involved in the patient’s care.

The treatment plan is the consensus outcome of a multidisciplinary meeting discussion and reflects decisions made around cancer therapy including systemic therapy (chemotherapy and targeted therapy) and other modalities such as surgery and radiotherapy. The plan should reflect the intent of the treatment and requirements in relation to nursing, allied health and palliative care. Where an MDT is not in existence within an institution, it is recommended that clinicians link into a centre that does hold such meetings.


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Evidence Summary

A treatment plan containing information relevant to a patient’s management improves safety in the delivery of cancer treatment and ensures consistent communication to all healthcare providers that encounter the patient. A plan increases ease of access to information required for treatment-related decision-making.[1][2]

The inclusion in the plan of relevant medical conditions/co-morbidities, medications and adverse drug reactions is of particular importance for ensuring assessment of potential serious toxicities (e.g. coronary vasospasm with fluoropyrimidines or medication interactions such as warfarin and capecitabine).[3][4] Table 5 indicates content that should be included in a treatment plan.

Clinical justification for the deviation from accepted protocols and dosing schedules must be documented to include published references where applicable.[5]


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Recommendations

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A treatment plan must be completed for all patients receiving cancer therapy by the clinician initiating treatment and be available in a patient’s healthcare record at all times.


The treatment plan should follow a standard template and ideally be in a computer-generated format to ensure all required information is included.


The patient’s overall treatment plan should be discussed in a multidisciplinary meeting and should reflect other decisions made such as surgery and radiation therapy and requirements for nursing and allied health services. Where an MDT is not in existence within an institution, it is recommended that clinicians link into a centre that does hold such meetings.


Deviations from accepted protocols and dosing schedules must be documented in the plan and include clinical justification for the deviation or alteration. Published references supporting a deviation or change to the original protocol must be citied where applicable.


The treatment plan should be made available to the patient in a ‘patient friendly’ format to support shared decision making and ensure all healthcare providers that care for the patient have access to the overall plan for cancer treatment.


Where the treatment plan changes during treatment (e.g. if the patient is commenced on a new protocol or the dose changes) this should be clearly documented on the treatment plan, including the clinical justification (Goldspiel et al, 2015).


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The treatment plan should include relevant background medical conditions, medications and adverse reactions to medications (Goldspiel et al, 2015) and a schedule of follow-up clinical visits and investigations (e.g. expected blood tests, three-monthly transthoracic echocardiogram with anti-Her2 agents).


The treatment plan should include necessary baseline assessments such as imaging, laboratory and functional investigations tailored to the patient and the proposed treatment (e.g. transthoracic echocardiogram to assess cardiac structure and function prior to potentially cardiotoxic agents such as anthracyclines or trastuzumab, or respiratory function testing prior to bleomycin). Other baseline interventions should also be documented, for example, fertility preservation such as sperm banking.


The American Society for Clinical Oncology (ASCO) Institute for Quality provides useful cancer treatment plan templates (ASCO Institute for Quality).

(Goldspiel et al, 2015)[1] ;(ASCO Institute for Quality, 2017)[6]


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Tables

Table 5: Suggested content of treatment plan

Patient name and TWO other unique identifiers (e.g. hospital number, date of birth)
Diagnosis
Background medical history, medications and allergies
Name and reference number (where appropriate) of the cancer therapy/chemotherapy protocol
Any deviations or alteration to the documented cancer therapy/chemotherapy protocol including clinical justification
The date treatment is intended to commence
Intended duration of treatment and the number of cycles for treatment
Tests to be performed after specified number of cycles
Therapeutic goal of treatment (e.g. curative, palliative)
Details of other therapeutic modalities (e.g. surgery, radiotherapy)


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References

  1. 1.0 1.1 Goldspiel B, Hoffman JM, Griffith NL, Goodin S, DeChristoforo R, Montello CM, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm 2015 Apr 15;72(8):e6-e35 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25825193.
  2. Cox S, Lappan J, Nayiager T, MacDonald P, Maric Z, Athale U. Chemotherapy passport: A tool to improve safe delivery of chemotherapy. Pediatric Blood and Cancer 2012;59(6):1118.
  3. Hanigan MH, Dela Cruz BL, Shord SS, Medina PJ, Fazili J, Thompson DM. Optimizing chemotherapy: concomitant medication lists. Clin Pharmacol Ther 2011 Jan;89(1):114-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21124312.
  4. Maggiore RJ, Dale W, Gross CP, Feng T, Tew WP, Mohile SG, et al. Polypharmacy and potentially inappropriate medication use in older adults with cancer undergoing chemotherapy: effect on chemotherapy-related toxicity and hospitalization during treatment. J Am Geriatr Soc 2014 Aug;62(8):1505-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25041361.
  5. NSW Health Department. Off-protocol prescribing of chemotherapy for head and neck cancers. Inquiry under section 122 of the Health Services Act 1997.; 2016 [cited 2016 Sep] Available from: http://www.health.nsw.gov.au/Hospitals/Documents/section-122-final-report.pdf.
  6. American Society of Clinical Oncology (ASCO) Institute for Quality. Cancer Treatment Plan and Summary Templates. [homepage on the internet]; 2017 [cited 2016 Sep]. Available from: http://www.instituteforquality.org/cancer-treatment-plan-and-summary-templates.

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