Interventional Radiology in Palliative Care (Medical Radiology) 3030654621, 9783030654627

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Medical Radiology · Diagnostic Imaging Series Editors: Hans-Ulrich Kauczor · Paul M. Parizel · Wilfred C. G. Peh

Peter L. Munk Suresh B Babu   Editors

Interventional Radiology in Palliative Care

Medical Radiology Diagnostic Imaging Series Editors Hans-Ulrich Kauczor Paul M. Parizel Wilfred C. G. Peh

The book series Medical Radiology – Diagnostic Imaging provides accurate and up-to-date overviews about the latest advances in the rapidly evolving field of diagnostic imaging and interventional radiology. Each volume is conceived as a practical and clinically useful reference book and is developed under the direction of an experienced editor, who is a world-renowned specialist in the field. Book chapters are written by expert authors in the field and are richly illustrated with high quality figures, tables and graphs. Editors and authors are committed to provide detailed and coherent information in a readily accessible and easy-to-understand format, directly applicable to daily practice. Medical Radiology – Diagnostic Imaging covers all organ systems and addresses all modern imaging techniques and image-guided treatment modalities, as well as hot topics in management, workflow, and quality and safety issues in radiology and imaging. The judicious choice of relevant topics, the careful selection of expert editors and authors, and the emphasis on providing practically useful information, contribute to the wide appeal and ongoing success of the series. The series is indexed in Scopus. For further volumes: http://www.springer.com/series/4354

Peter L. Munk  •  Suresh B Babu Editors

Interventional Radiology in Palliative Care

Editors Peter L. Munk Vancouver General Hospital Vancouver Coastal Health Research Institute Vancouver, BC, Canada

Suresh B Babu Department of Diagnostic Radiology Khoo Teck Puat Hospital Yishun Central Singapore, Singapore

ISSN 0942-5373     ISSN 2197-4187 (electronic) Medical Radiology ISBN 978-3-030-65462-7    ISBN 978-3-030-65463-4 (eBook) https://doi.org/10.1007/978-3-030-65463-4 © Springer Nature Switzerland AG 2021, corrected publication 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

It gives me great personal pleasure to write the Foreword for this book, Interventional Radiology in Palliative Care. The idea for proposing this book was not difficult. Professor Peter L. Munk, my good friend of more than 20 years standing and senior author of this book, has, over the recent few years, gained prominence speaking on musculoskeletal (MSK) interventional radiology (IR) procedures in palliative care at conferences in different parts of the world. With the field of palliative care growing in importance, and the expanding and increasingly vital role of IR in treating these patients, it is logical to see the need for a book that comprehensively addresses this niche area. The lead author Dr Suresh B Babu is a respected senior interventional radiologist in Singapore and serves as IR Chief at Khoo Teck Puat Hospital (KTPH), Singapore. As geriatric medicine is one of the leading clinical subspecialties in KTPH, the IR team has extensive experience dealing with patients needing palliative treatment. Suresh knows Peter well, having done his IR Fellowship at Vancouver General Hospital (VGH), University of British Columbia (UBC), many years ago, when he was still practicing in the UK. Over the past two decades, many young Singaporean radiologists from various local hospitals did their advanced Fellowships in VGH/UBC, particularly in MSK radiology and IR; and many Canadian radiologists have visited Singapore as faculty and visiting experts. This book mirrors our close Singapore-Canadian links, supplemented by contributions from experts hailing from top centers in the UK, France, and the USA. The organization of Interventional Radiology in Palliative Care reflects the vast experience of the two senior authors and the importance of collaboration with clinical colleagues, particularly palliative care physicians. Following introductions of palliative care and IR in general, key topics— clinical outcome measures, ethics, consent and communication, and nutrition—are addressed. The book then turns to focused approaches to problem-solving, providing solutions to many specific topics relating to musculoskeletal and neurological pain relief, tumor debulking, bleeding, and obstruction in various hollow organs. Drainages in different parts of the body are dealt with in detail, as are fistula treatment and finally, intrathecal pain pumps. This book will be valuable not only to interventional radiologists, palliative care physicians, and oncologists, but will be useful to all other v

Foreword

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professionals caring for and aiming to provide their patients with an improved quality of life, albeit under inherently difficult circumstances. With a globally ageing population on the rise, the need for palliative care treatment options will be expected to increase. October 2020

Singapore

Wilfred C. G. Peh Department of Diagnostic Radiology Khoo Teck Puat Hospital Singapore, Singapore Yong Loo Lin School of Medicine National University of Singapore Singapore, Singapore

Preface

Over the last generation, huge advances in Interventional Radiology (IR) have occurred, revolutionizing the way we treat innumerable medical conditions. Not a year goes by without new procedures being devised to address ever more clinical situations. Even for those of us in Radiology, it is often hard to keep up with these improvements. A number of months ago, we were approached by our colleague and friend Professor Wilfred Peh of the National University of Singapore and Khoo Teck Puat Hospital, Singapore, who in his capacity as Book Series Editor for Springer, first proposed the idea for this book. He pointed out that relatively little existed on the market that addressed the needs that existed in the field of Palliative Care that could be addressed using the skills and experience that has been accrued by IR. Bouncing the idea off our Palliative Medicine colleagues, two things became apparent. First, clinicians who referred their patients for imaging-­ guided IR procedures are generally appreciative of the positive impact these procedures have on their patient’s quality of life. IR procedures make end-of-­ life care much more successful and easier. Second, it was clear that many Palliative Medicine physicians (and other clinicians involved in care of patients receiving palliative care) are often poorly informed about what IR can do to facilitate end-of-life care of their patients. This book represents the consequence of these many discussions. What follows is the combined experience and wisdom of many IR radiologists and Palliative Medicine physicians from around the world. Without the shared experience and knowledge of these contributors, this book would have never seen the daylight. First and foremost, we hope that this book may facilitate the delivery of care that will improve the quality of life for our patients. We also hope that it will inspire those performing procedures to expand their repertoire thereby further expanding what they are able to do for their patients. Finally, we hope this will give Palliative Care physicians a broader idea of the many clinical situations where IR can augment the care of their patients. Our project coordinators, Ms Shanti Ramamoorthy and Mr M. Vignesh are the guiding lights for this book. They constantly dragged us to the right path and set us on it. We also wish to acknowledge support and guidance from the Springer Management Team, Ms Barbara Zoehrer and Ms Rosemarie Unger. We also wish to acknowledge the support and succour provided by our family. I (Peter L. Munk) have always depended on and greatly treasured the vii

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encouragement of my wife Maria Chung and our three daughters Charlotte, Eleanor, and Sophie Munk. I (Suresh B Babu) am grateful for the life support given to me by Saraswathy, Sophie, Sammie, Sashti, and Sharvi Babu. This would not have been possible without the strong support from our friends and colleagues, from our respective departments, from Vancouver and Singapore, and you know who you are. Thank You! We are grateful to our patients, teachers, and colleagues for teaching us medicine, guiding us through our careers, and letting us practice this healing art of advanced speciality IR. To the patients! Vancouver, BC, Canada Singapore, Singapore 

Peter L. Munk Suresh B Babu

Contents

Part I Introduction and Nutrition Introduction to Palliative Care ��������������������������������������������������������������   3 Pippa Hawley Introduction to IR������������������������������������������������������������������������������������  11 Luke Lintin and Raman Uberoi Clinical Applications of Outcome Measurement����������������������������������  19 Mansha H. Khemlani  Ethics, Consent, and Communication Challenges��������������������������������  29 Chua Zi’en Ruth, Pijush Sarker, and Mansha H. Khemlani Intravenous Access Solutions������������������������������������������������������������������  35 Rahul Lohan and Kabilan Chokkapan Feeding Solutions ������������������������������������������������������������������������������������  47 Sivasubramanian Srinivasan, Karthiraj Natarajan, and Krishna Mohan Gummala Part II Musculoskeletal Pain Relief Solutions  Imaging-Guided Palliative Procedures: Tendon and Bursa Injection ����������������������������������������������������������������������������������������  59 Anesh Chavda, Alexandra Pender, and Mark Cresswell Cement Consolidation: Vertebral Augmentation and Cementoplasty������������������������������������������������������������������������������������������  71 Steven Yevich Palliative Bone Tumors Thermal Ablation��������������������������������������������  81 Roberto Luigi Cazzato, Julien Garnon, and Afshin Gangi Part III Neurological Pain Relief Solutions Epidural Steroid Injections ��������������������������������������������������������������������  93 Ashutosh Joshi and Wern Hsien Bin Spinal Facet Injections for Palliative Pain Management �������������������� 105 Will Guest and Manraj Heran ix

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 Spinal Nerve Root Blocks������������������������������������������������������������������������ 117 Hong Chou Nerve Blocks (Non-spinal)���������������������������������������������������������������������� 131 Eelin Tan, Sum Leong, and Chow Wei Too Autonomic Blocks������������������������������������������������������������������������������������ 149 Rahul Lohan and Andrzej Krol Part IV Tumour Debulking Solutions Endovascular Embolisation Techniques������������������������������������������������ 163 Suresh B Babu, Sivasubramanian Srinivasan, Raymond Chung, Rahul Lohan, and Hsien Khai Tan Tumour Ablations������������������������������������������������������������������������������������ 169 Sivasubramanian Srinivasan Part V Bleeding Solutions  Bleeding Solutions in the Head and Neck���������������������������������������������� 183 Prasanna S. Tirukonda Gastro-intestinal Bleed���������������������������������������������������������������������������� 191 Sivasubramanian Srinivasan  Bleeding Solutions for Genitourinary Tract������������������������������������������ 201 Apoorva Gogna and Farah Gillan Irani  Bleeding Solutions in Lung �������������������������������������������������������������������� 211 Nanda Venkatanarasimha, Karthikeyan Damodharan, Robert Chun Chen, Kristen Alexa Lee, and Sivanathan Chandramohan  Bleeding Solutions in Hepatobiliary Pancreatic Systems�������������������� 227 Seung Wook Ryu and Uei Pua  Bleeding Solutions for Fungating Masses���������������������������������������������� 235 Karthikeyan Damodharan, Nanda Venkatanarasimha, Kristen Alexa Lee, and Sivanathan Chandramohan Part VI Obstruction Solutions  Malignant Bile Duct Obstruction (MBDO): Obstruction Solutions for Liver and Gallbladder������������������������������������������������������ 243 Kheng Song Leow and Rahul Lohan  Obstruction Solutions for Kidneys and Urinary Bladder�������������������� 259 Tan Hsien Khai Role of IR in Large Bowel Obstruction ������������������������������������������������ 267 John Francis Leahy

Contents

Contents

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Part VII Drainages Effusions��������������������������������������������������������������������������������������������������� 279 Chantal Z. J. Liu and Raymond J. H. Chung  Ascites and Fluid Collections������������������������������������������������������������������ 291 Chantal Z. J. Liu and Raymond J. H. Chung Abscesses�������������������������������������������������������������������������������������������������� 303 S. Z. Tang and Raymond J. H. Chung Part VIII Miscellaneous Treatment of Fistulas ������������������������������������������������������������������������������ 321 Kristen Alexa Lee, Nanda Venkatanarasimha, Karthikeyan Damodharan, and Sivanathan Chandramohan  Intrathecal Pain Pumps: Placement and Management������������������������ 333 Douglas P. Beall, Dereck D. Wagoner, Edward S. Yoon, Brooks M. Koenig, Jennifer Witherby, Michael E. Flamm, Adrea S. Knoll, Andrew W. Favre, Greg Pace, Elizabeth Bolen, Madelyn Nordgren, and Todd Russell Correction to: Nerve Blocks (Non-spinal) . . . . . . . . . . . . . . . . . . . . . . . C1 Eelin Tan, Sum Leong, and Chow Wei Too

Part I Introduction and Nutrition

Introduction to Palliative Care Pippa Hawley

Contents 1     Introduction

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2     What Is Palliative Care?

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3     Why Is This Important for Interventional Radiologists?

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4     The History of Palliative Care

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5     The “Upstreaming” of Palliative Care

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6     Specialist Palliative Care

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7     Awareness of Services

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8     The Place of Interventional Radiology in Palliative Care

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9     Practical Considerations with Interventional Radiological Palliative Procedures

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10    Summary

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References

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Abstract

Interventional radiological techniques are proving to be vital in the relief of physical suffering and improving function, both of which are also goals for modern palliative care. The P. Hawley (*) UBC Division of Palliative Care, UBC Department of Medicine, Pain and Symptom Management/Palliative Care Program, BC Cancer, Vancouver, BC, Canada e-mail: [email protected]

need for all medical specialties to be able to deliver at least basic palliative care as a core competency is now widely recognized. A Palliative Approach to Care provided by a diverse range of health care professionals from the time of diagnosis can meet the needs of most patients and their families living with serious illnesses, allowing Specialist Palliative Care services to take care of those with the most complex needs. Palliative care primarily impacts three domains: symptom management, communication around goals of care,

© Springer Nature Switzerland AG 2021 P. L. Munk, S. B Babu (eds.), Interventional Radiology in Palliative Care, Medical Radiology Diagnostic Imaging, https://doi.org/10.1007/978-3-030-65463-4_1

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P. Hawley

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and collaboration between all the different people and services involved. Awareness of how interventional radiologists, anesthesiologists and specialist palliative care teams can collaborate is particularly important when carrying out procedures on people with complex needs who are suffering greatly. A common understanding of the principles of palliative care will facilitate future integration throughout the health care system so that the relief of suffering for our most vulnerable patients is promptly achieved, whatever their prognosis.

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Introduction

Suffering is experienced by persons, not merely by bodies, and has its source in challenges that threaten the intactness of the person as a complex social and psychological entity. Suffering can include physical pain but is by no means limited to it. The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself (Cassel 1982). Being diagnosed with a life-threatening disease causes suffering in physical, psychological, social and spiritual domains, but one could presume that the most extreme suffering we see would be seen in those who choose Medical Assistance in Dying (MAiD). In Canada, where MAiD has been legal since 2016, the majority of recipients have been cancer patients and the most common reasons for choosing this mode of death are: • Loss of control and independence • Loss of ability to do enjoyable and meaningful activities • Fear of future suffering • Illness-related physical suffering

For every patient who actually goes through with MAiD there are many who consider it, and for most of them it is the fear of future suffering that is the primary source of distress.

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What Is Palliative Care?

Palliative Care can be described briefly as a way of caring for people with life-threatening illnesses which focuses on quality of life. The definitions used by the World Health Organization (https://www.who.int/cancer/palliative/definition/en/), Canadian Society of Palliative Care Physicians (http://www.cspcp.ca/wp-­content/ uploads/2016/11/Full-­Report-­How-­to-­Improve-­ Palliative-­C are-­i n-­C anada-­F INAL-­N ov-­2 016. pdf), and the US’s Centre to Advance Palliative Care (https://www.capc.org/about/palliative-­ care/websites) all describe palliative care similarly, as an approach to care that addresses patient needs in the physical, social, psychological, and spiritual domains. Three main components are described: 1. Meticulous prevention and management of symptoms, including pain 2. Excellence in communication, in discussion of goals of care and advance care planning 3. An extra layer of support for practical needs, particularly with respect to care provided at the patient’s home

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 hy Is This Important W for Interventional Radiologists?

Patients receiving curative and palliative disease-­ modify treatments are generally ambulatory, and the most cost-effective way of meeting their needs will be in the outpatient clinic setting. Minimally invasive palliative procedures have a very important role in the prevention and management of pain and loss of function, especially in cancer, and can keep patients in a state of comfort and functional capacity to allow them to stay

Introduction to Palliative Care

at home. A coordinated Palliative Care strategy to minimize suffering for people with serious illnesses should include patients having timely access to a wide range of palliative procedures. Interventional radiologists are very much a part of a modern integrated interprofessional/multidisciplinary palliative care team. In order to become part of the team, radiologists must have at least basic palliative care skills, and have an understanding of the nature of modern palliative care when communicating with patients and colleagues of all disciplines.

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The History of Palliative Care

The first known “hospice” was opened as a refuge for travelers and the sick by the Order of the Knights Hospitaller of St. John of Jerusalem in Rhodes. The concept was adopted by the Catholic Church and the hospice of L’Association des Dames de Calvaire was founded by Jeanne Garnier in1843, focusing on lepers, the destitute, and the dying. Other hospices were opened by other church-associated charities, particularly in the USA, Australia, Ireland, and England in the 1800s, extending their reach to include people suffering from tuberculosis and incurable cancer. Based on knowledge of the effects of opium, morphine was invented in the 1820s, initially only as an injectable liquid, and the combination of poor hypodermic syringe and needle technology with widespread recognition of opioids in the addiction context did not make it an attractive proposition as an analgesic. The first modern hospice (St. Christopher’s) was founded by Dame Cicely Saunders in London, England in 1967, after Dr. Saunders realized that people who were dying needed a different approach to care than was the norm in health care at the time, which focused very much on disease management. The appearance of orally administered morphine was a key facilitator in this. Physicians from all over the world visited St Christopher’s and brought back De. Saunders’ ideas, leading to the opening of similar centers around the world,

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some of the earliest being in Canada. The term “Palliative Care” (in French: Soin Palliatif) was actually coined by Canadian urologist Dr. Balfour Mount in the 1970s because of the historical associations of the term “Hospice” in the Canadian francophone community. This renaming facilitated the spread of palliative care programs around the world in the latter part of the twentieth century, and originally the term served its purpose well. Palliative Care Units opened in many hospitals. Though small in number of beds, their impact was leveraged by outreach from staff in these units to provide consultation, education, and research throughout the health care environment, and the opening of residential hospices was made possible by volunteers and philanthropists.

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The “Upstreaming” of Palliative Care

The start of the twenty-first century coincided with a growing awareness of the benefits of having access to palliative care early in the course of illness, with some seminal clinical trials demonstrating not just the expected improvements in symptom severity and quality of life of patients and their caregivers/loved ones, but also a reduction in use of inappropriate interventions in the last weeks of life (like ICU admissions and chemotherapy), but also reductions in the costs of care without any shortening of survival. In fact, early palliative care intervention studies usually showed longer survival for recipients. This attracted the attention of health care administrators keen to reduce health care spending without perception of loss of care quality. Unfortunately, many patients accessed these programs very late in their illness, and for many it was too late to achieve the maximum potential benefits from this kind of care. One of the most challenging barriers to early access to palliative care was the understandable general perception that palliative care and hospice programs were only appropriate for people who were dying. Originally synonymous, and in the absence of any new language, a need

P. Hawley

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for separation of the terms Palliative Care and Hospice began to emerge. Contrary to what many people believe, modern palliative care can be provided alongside treatments targeting the underlying disease and may be needed from the time of diagnosis. Similarly, treatments targeting control of disease may be required alongside palliative care, right up to the time of death. Both approaches are necessary and should have equal value, whether in a high resource health care system with many treatment options, or in a developing setting where patients are diagnosed late in the course of illness and few curative treatments are available. Advances in medicine, for example in antiviral drugs, organ transplantation, and oncology treatments, have changed the landscape for many people with what used to be thought of as inevitably fatal diseases. Hopefully similar advances in other illnesses such as neurodegenerative and hereditary disease will be following through the lifetimes of you, the readers, but these amazing advances come inextricably packaged with increasing confusion about what to expect as we age. Acceptance of our mortality is becoming progressively more hampered by uncertainty. A sense of needing to “never give up” is pervasive in the media, with patients and their loved ones vacillating between needing to prepare for death whilst simultaneously having a potentially realistic hope for survivorship on a daily basis. Modern palliative care includes hospice care, including end of life care, but also includes

early integrated supportive care from the time of diagnosis, and as modern medical treatments progress, it is clear that at least some patients will actually survive their illness, transitioning to survivorship through a period of rehabilitation, when the prognosis can be very uncertain. This concept of need for simultaneous disease-­ targeting and palliative approaches to care has taken a long time to become established, especially in areas other than cancer care. Though the AIDS epidemic in the 1980s and 90s did lead to the opening of some hospices and palliative care programs that did not focus on cancer patients, the needs of people with other life-threatening chronic conditions such as heart or kidney failure, chronic lung disease and neurodegenerative diseases are only relatively recently starting to acknowledge the need for a palliative approach to care and to access support from specialist palliative care programs. This new model of care for patients with serious illnesses is illustrated in the “Bow Tie Model of Twenty-First Century Palliative Care” (Hawley 2014) (Fig. 1). The words used in the model can be adjusted to different cultures, but the basic principle the model tries to convey is the need acknowledge the possibility of survivorship in order to engage patients early enough in the course of their illness to make a difference to outcomes. This can be communicated to patients and families as “hope for the best, and prepare for the rest.”

Cure Disease Management

Rehabilitation

Palliative Care

Integrated Supportive Care

Control

Survivorship

Hospice

Bereavement

Fig. 1  The Bow Tie Model of Twenty-First Century Palliative Care, modified from Hawley P, 2014 (Hawley 2014)

Introduction to Palliative Care

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Specialist Palliative Care

The number of specialist palliative care physicians, nurses, social workers, pharmacists, physiotherapists, music therapists, art therapists and other professionals is totally inadequate for even a minority of patients who are living with serious chronic illness to be able to access specialty palliative care services, and never will be, given that about 90% of us will die from a chronic illness and will have plenty of time to see death coming. A palliative approach to care has to be able to be provided by family doctors and specialists in all other areas of medicine in order to meet the majority of patients’ and their families’ needs. The specialist services need to be able to target their care to those who have the most complex needs or the most extreme suffering. The ­proportion of patients and families needing specialist palliative care will vary from place to place depending on the skills and resources available through primary care. In an ideal world, all health care professionals’ training would include basic palliative care competencies, but in reality, this has yet to happen, so the threshold for specialist referral is appropriately quite variable. Recognition of when the point of unmet need occurs can be difficult, especially where there is no routine distress screening. Discretionary referral alone cannot be relied on to provide a timely and appropriate referral practice. Triggers to refer can be activated automatically when transitions in care are documented (e.g., on detection of metastases in cancer care); or by expression of distress recognized through use of screening tools. As distress can occur at any time in the course of illness, screening should occur regularly from the time of diagnosis. Prompt referral for specialist palliative care support should be made at any time when physical, social, psychological, or spiritual unmet needs are not able to be satisfactorily resolved by the primarily caring team (which may include a variety of specialists as well as family medicine/general practice), including when the goal of disease management is curative in intent. Patients do best by having access to both disease-­modifying treatments and palliative care

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simultaneously, so it makes no sense to hand over all aspects of care to a service with limited resources when a referral is made. The most efficient model of care is to have the right people delivering the care at the right time that most suits the circumstances. Who is “right” may change a number of times over the course of a long illness, and palliative care professionals can most efficiently and cost-effectively share their expertise at multiple points in the illness trajectory, stepping back when not needed, ensuring ongoing care is provided by the referring team.

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Awareness of Services

Just as many health care providers working outside a tertiary hospital environment are unaware of the procedures that interventional radiology programs can provide for patients, similarly physicians who have done little postgraduate training in settings where they have long-term clinical relationships with patients may be unfamiliar with the challenges of living with a long-term illness, deriving much of their knowledge from personal experience with family and friends rather than from formal training. The trend for residential hospices to be freestanding buildings in pleasant locations away from urban hospitals can lead to lack of awareness of their existence. Students and residents infrequently have access to palliative care rotations, and the paucity of palliative care teaching in many medical school and residency programs make it difficult for physicians to understand what happens in a specialist palliative care setting. It is therefore important for palliative care teams to interact with their colleagues in other specialties on a regular basis, attending rounds, teaching, and participating in committee work. The same applies to specialists in procedure-based disciplines, so that mutual understanding of the important issues is shared and services can be developed optimally. This can be challenging when added to the responsibilities of professionals who are already overloaded with clinical work and needs to be taken into consideration in workforce planning and staffing models.

P. Hawley

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 he Place of Interventional T Radiology in Palliative Care

reports before and after cementoplasty included the following:

With respect to cancer pain, the World Health Organization’s Pain Relief Ladder now has “Step 4” interventions, which include interventional procedures, at the top of the ladder (Fig.  2). “Procedures” include neuraxial infusions, neurolytic procedures, regional anesthetic procedures, and other interventions such as cryoablation and cementoplasty. Many Step 4 procedures are in reality only available to a few patients, mostly those living close to tertiary referral centers. Their benefits in relief of suffering can be dramatic, and the cost-­effectiveness of palliative procedures for those with the worst suffering is undeniable. For example, in a review of the first year of a Minimally Invasive Palliative Procedures case conference in Vancouver, BC (Chu et al. 2015), there were 103 referrals to the case conference, resulting in 69 procedures performed among 63 patients. Over 80% of procedures provided analgesic benefit. Pain scores fell across all categories post-­procedure. Mean worst pain scores fell from 8.1 ± 1.4 to 4.6 ± 2.8 (P