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Seecof OM, Jang C, Abdul Hay M. Impact of Palliative Care Referral on End-of-Life Outcomes for Patients With Hematologic Malignancy. Am J Hosp Palliat Care 2024:10499091241266991. [PMID: 39041816 DOI: 10.1177/10499091241266991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
CONTEXT Compared to patients with solid malignancies, less is known about the role of palliative care in patients with hematologic malignancies, leading to underutilization of palliative care. OBJECTIVES Evaluate the timing and impact of palliative care referrals on end-of-life outcomes over a 5-year period with intent to improve the utilization of palliative care in patients with advanced hematologic malignancies. METHODS A retrospective cohort of patients from an urban, NCI-designated comprehensive cancer center, aged 18 years and older with a diagnosis of an advanced hematologic malignancy were separated into groups of early, late, very late, or no specialty palliative care. Logistic regression models were constructed to examine variables associated with timing of palliative care referral. Groups were compared using the Kruskal Wallis test and Dunn's test with a Bonferroni correction method. RESULTS 222 patients with advanced hematologic malignancies who died between July 1, 20218 and June 30, 2023 were included. 50 (23%), 41 (18%), and 51 (23%) patients received an early, late, and very late palliative care referral, respectively and 80 (36%) patients did not receive a palliative care referral. There was a significantly high completion of ACP documentation among the palliative care cohorts. There was no significant difference among all cohorts in end-of-life outcomes in the last 14 or 30 days of life. CONCLUSION ACP documentation improved with palliative care, however, end-of-life outcomes did not. These results are likely due to the majority of late, inpatient palliative care referrals. Future studies with targeted interventions are needed to improve these outcomes.
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Affiliation(s)
- Olivia M Seecof
- NYU Grossman School of Medicine, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Charley Jang
- NYU Grossman School of Medicine, New York, NY, USA
| | - Maher Abdul Hay
- NYU Grossman School of Medicine, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
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2
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Burstein R, Aviv A, Even-Zohar NG, Nachmias B, Haran A, Braun M, Rottenberg Y, Shaulov A. Comparing end-of-life care of hematologic malignancy versus solid tumor patients in a tertiary care center. Eur J Haematol 2023; 111:528-535. [PMID: 37385825 DOI: 10.1111/ejh.14035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To compare end-of-life (EOL) care for solid tumor and hematologic malignancy (HM) patients. METHODS We collected data on the last 100 consecutive deceased HM and 100 consecutive deceased solid tumor patients who died prior to June 1st 2020, treated at a single center. We compared demographic parameters, cause of death as ascertained by review of medical records by two independent investigators, and EOL quality indicators including: place of death, use of chemotherapy or targeted/biologic treatment, emergency department visits as well as hospital, inpatient hospice and Intensive Care Unit admissions and the time spent as inpatient over the last 30 days of life; mechanical ventilation and use of blood products during the last 14 days of life. RESULTS In comparison with solid tumor patients, HM patients more commonly died from treatment complications (13% vs. 1%) and unrelated causes (16% vs. 2%, p < .001 for all comparisons). HM patients died more frequently than solid tumor patients in the intensive care unit (14% vs. 7%) and the emergency department (9% vs. 0%) and less frequently in hospice (9% vs. 15%, p = .005 for all comparisons). In the 2 weeks prior to death HM patients were more likely than solid tumor patients to undergo mechanical ventilation (14% vs. 4%, p = .013), receive blood (47% vs. 27%, p = .003) and platelet transfusions (32% vs. 7%, p < .001); however, no statistical difference was found in use of either of chemotherapy (18% vs. 13%, p = .28) or targeted treatment (10% vs. 5%, p = .16). CONCLUSIONS HM patients were more likely than solid tumor patients to undergo aggressive measures at EOL. Rarity of HM deaths, frequently caused by complications of treatment and unrelated causes, may affect treatment choices at EOL.
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Affiliation(s)
- Rachel Burstein
- School of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Aviv
- Department of Hematology, HaEmek Medical Center, Afula, Israel
| | - Noa Gross Even-Zohar
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Arnon Haran
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Braun
- Breast Oncology Unit, Sharett Institute of Oncology, Hadassah Medical Center, Jerusalem, Israel
- School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
| | - Yakir Rottenberg
- Department of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Robert G, Chappe C, Ferreira A, Mc Ewan E, Calmanti S. Paediatric palliative care: why transfuse? BMJ Support Palliat Care 2023; 13:e110-e112. [PMID: 33468511 DOI: 10.1136/bmjspcare-2020-002582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/06/2021] [Indexed: 11/04/2022]
Abstract
Should indication for transfusion in paediatric palliative care be based on the child's perspective rather than the biological results? An 8-year-old boy presenting a relapse of a stage IV neuroblastoma received regular blood transfusions. A severe exophtalmia led the doctors to question the transfusion strategy. Over 7.5 months, the child received 56 red blood cell units and 31 platelet units. He was hospitalised 50 times. Indication for blood test and transfusion may be regularly and collegially reassessed. Transfusion needs in a palliative strategy can be as high as in a curative strategy. Practices, benefits but also ethical and public health dimensions should be more studied.
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Affiliation(s)
- Guillaume Robert
- Palliative Care Centre, University Hospital, Rennes, Bretagne, France
- Paediatric Palliative Care Regional Team - ERRSPP Bretagne - La Brise, Rennes, Bretagne, France
- Université Rennes 1, Rennes, Bretagne, France
| | - Celine Chappe
- Paediatric Oncology Unit, University Hospital, Rennes, Bretagne, France
| | - Ana Ferreira
- Paediatric Palliative Care Regional Team - ERRSPP Bretagne - La Brise, Rennes, Bretagne, France
| | - Elisabeth Mc Ewan
- Palliative Care Centre, University Hospital, Rennes, Bretagne, France
| | - Sara Calmanti
- Paediatric Palliative Care Regional Team - ERRSPP Bretagne - La Brise, Rennes, Bretagne, France
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Korsos V, Ali A, Malagon T, Khosrow-Khavar F, Thomas D, Sirhan S, Davison K, Assouline S, Cassis C. End of life in haematology: quality of life predictors - retrospective cohort study. BMJ Support Palliat Care 2023:spcare-2023-004218. [PMID: 37068924 DOI: 10.1136/spcare-2023-004218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/15/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES Haematology patients are more likely to receive high intensity care near end of life (EOL) than patients with solid malignancy. Previous authors have suggested indicators of quality EOL for haematology patients, based on a solid oncology model. We conducted a retrospective chart review with the objectives of (1) determining our performance on these quality EOL indicators, (2) describing the timing of level of intervention (LOI) discussion and palliative care (PC) consultation prior to death and (3) evaluating whether goals of therapy (GOT), PC consultation and earlier LOI discussion are predictors of quality EOL. METHODS We identified patients who died from haematological malignancies between April 2014 and March 2016 (n=319) at four participating McGill University hospitals and performed retrospective chart reviews. RESULTS We found that 17% of patients were administered chemotherapy less than 14 days prior to death, 20% of patients were admitted to intensive care, 14% were intubated and 5% were resuscitated less than 30 days prior to death, 18% of patients received blood transfusion less than 7 days prior to death and 67% of patients died in an acute care setting. LOI discussion and PC consultation occurred a median of 22 days (IQR 7-103) and 9 days (IQR 3-19) before death. Patients with non-curative GOT, PC consultation or discussed LOI were significantly less likely to have high intensity EOL outcomes. CONCLUSIONS In this study, we demonstrate that LOI discussions, PC consults and physician established GOT are associated with quality EOL outcomes for patients with haematological malignancies.
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Affiliation(s)
- Victoria Korsos
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Alla'a Ali
- Rossy Cancer Network, Montreal, Quebec, Canada
| | - Talia Malagon
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Farzin Khosrow-Khavar
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
- Department of Biostatistics and Epidemiology, Rutgers University, New Brunswick, New Jersey, USA
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | | | - Shireen Sirhan
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Kelly Davison
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sarit Assouline
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Chantal Cassis
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
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5
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Shaulov A, Aviv A, Alcalde J, Zimmermann C. Early integration of palliative care for patients with haematological malignancies. Br J Haematol 2022; 199:14-30. [PMID: 35670630 PMCID: PMC9796711 DOI: 10.1111/bjh.18286] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/30/2022] [Accepted: 05/17/2022] [Indexed: 01/07/2023]
Abstract
Early palliative care (EPC) significantly improves quality of life, symptoms, and satisfaction with care for patients with advanced cancer. International organizations have recognized and promoted the role of palliative care as a distinct specialty, advocating its involvement throughout the cancer trajectory. Although patients with haematologic malignancies (HMs) have a comparable symptom burden to patients with solid tumours, they face multiple barriers to EPC integration. In this review, we discuss these barriers, present updated evidence from clinical trials of EPC in HMs and propose models to support EPC integration into care for patients with HMs.
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Affiliation(s)
- Adir Shaulov
- Department of HaematologyHadassah Medical CenterJerusalemIsrael,Faculty of MedicineHebrew University of JerusalemIsrael
| | - Ariel Aviv
- Department of HaematologyHaEmek Medical CenterAfulaIsrael
| | - Jacqueline Alcalde
- Department of Supportive Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada,Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
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6
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Fan BE, Christopher D, Gallardo CA, Sampath VS. Rationalising red blood cell transfusions in advanced haematological malignancies: a patient-centred approach. THE LANCET. HEALTHY LONGEVITY 2022. [DOI: 10.1016/s2666-7568(21)00277-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Borregaard Myrhøj C, Novrup Clemmensen S, Sax Røgind S, Jarden M, Toudal Viftrup D. Serious illness conversations in patients with multiple myeloma and their family caregivers-A qualitative interview study. Eur J Cancer Care (Engl) 2021; 31:e13537. [PMID: 34734446 DOI: 10.1111/ecc.13537] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/02/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients treated for multiple myeloma often suffer from anxiety and depression related to concerns about the future. This indicates a need for improvement of communication between patients and healthcare professionals within haematology. The aim of this study was to explore how patients with multiple myeloma and their caregivers experience serious illness conversation focusing on illness understanding, concerns, values, and wishes for the future. METHODS Phenomenological, semi-structured dyad interviews were carried out in patients with multiple myeloma (n = 12) and their caregivers (n = 11) 2-20 days after participation in one serious illness conversation. interpretive phenomenological analysis was used for analysing data. RESULTS Three themes emerged (1) transforming patient-caregiver communication, (2) redeeming communication, and (3) equality in communication in an unequal relation. Furthermore, time allocated for the conversation and preparatory materials for the conversations highly influenced outcome. CONCLUSION The findings suggest that serious illness conversation can help patients and family caregivers managing living life with multiple myeloma by increasing dyadic communication and strengthen their use of existential language together with healthcare professionals. This study highlights the benefits of preparing patients and caregivers prior to the conversation and cancer care systems should strive to allocate ample time for serious illness conversations.
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Affiliation(s)
| | - Stine Novrup Clemmensen
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Signe Sax Røgind
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mary Jarden
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorte Toudal Viftrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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8
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Salazar MM, DeCook LJ, Butterfield RJ, Zhang N, Sen A, Wu KL, Vanness DJ, Khera N. End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. J Palliat Med 2021; 25:97-105. [PMID: 34705545 DOI: 10.1089/jpm.2021.0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.
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Affiliation(s)
- Marisa M Salazar
- Mayo Clinic Alix School of Medicine, Mayo Clinic College of Science and Medicine, Scottsdale, Arizona, USA
| | - Lori J DeCook
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Nan Zhang
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelly L Wu
- Division of General Internal Medicine, Center for Palliative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - David J Vanness
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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9
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Mun S, Wang R, Ma X, Ananth P. Sociodemographic and hospital-based predictors of intense end-of-life care among children, adolescents, and young adults with hematologic malignancies. Cancer 2021; 127:3817-3824. [PMID: 34185881 PMCID: PMC8478813 DOI: 10.1002/cncr.33764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/07/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children, adolescents, and young adults with hematologic malignancies tend to receive high-intensity end-of-life care (HI-EOLC), but sociodemographic and hospital-based predictors of HI-EOLC remain unclear. METHODS The authors conducted a population-based, retrospective cohort study with the Premier Healthcare Database. They identified individuals with hematologic malignancies who were 0 to 39 years old at death and died between 2010 and 2017. HI-EOLC was defined as experiencing 2 or more of the following: cardiopulmonary resuscitation, intravenous chemotherapy, hemodialysis, mechanical ventilation, tracheostomy placement, or an emergency department visit within the last 30 days of life and death in the intensive care unit. Multivariable logistic regression models were constructed to identify patient sociodemographic and hospital characteristics associated with HI-EOLC. RESULTS Among 1454 decedents, more than half (55%) experienced HI-EOLC. In multivariable models, patients treated in medium (adjusted odds ratio [aOR], 1.63; 95% confidence interval [CI], 1.07-2.50) or large hospitals (aOR, 2.21; 95% CI, 1.45-3.39), insured by Medicaid (aOR, 1.40 ; 95% CI, 1.09-2.06), or receiving cancer-directed treatment in the Northeast (aOR, 1.50; 95% CI, 1.05-2.15) were more likely to receive HI-EOLC. CONCLUSIONS A majority of children, adolescents, and young adults with hematologic malignancies experienced HI-EOLC, and the likelihood of HI-EOLC was influenced by the hospital size, type of insurance, and geographic region. Further research is needed to determine how to mitigate these risks.
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Affiliation(s)
- Sophia Mun
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Prasanna Ananth
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Pediatrics, Yale School of Medicine, New
Haven, CT
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10
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Yotani N, Shinjo D, Kato M, Matsumoto K, Fushimi K, Kizawa Y. Current status of intensive end-of-life care in children with hematologic malignancy: a population-based study. BMC Palliat Care 2021; 20:82. [PMID: 34098925 PMCID: PMC8186077 DOI: 10.1186/s12904-021-00776-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Adult patients with hematologic malignancies are less likely to receive palliative care and more likely to accept intensive anti-cancer treatments until end-of-life than those with solid tumors, but limited data are available regarding the quality of end-of-life care (EOLC) for children with hematologic malignancies. To improve the quality of EOLC for children with hematologic malignancies, the aims of this study were (i) to compare intensive EOLC between children with hematologic malignancies and those with solid tumors; and (ii) to describe factors associated with intensive EOLC in children with hematologic malignancies. Methods We retrospectively reviewed 0- to 18-year-old patients with cancer, who died in hospital between April 2012 and March 2016 in Japan using the Diagnosis Procedure Combination per-diem payment system. Indicators of intensive inpatient EOLC were defined as intensive care unit admission, cardiopulmonary resuscitation (CPR), intubation and/or mechanical ventilation, hemodialysis, or extra-corporeal membrane oxygenation in the last 30 days of life, or intravenous chemotherapy in the last 14 days. We determined factors associated with intensive EOLC using regression models. Data regarding use of blood transfusion were also obtained from the database. Results Among 1199 patients, 433 (36%) had hematological malignancies. Children with hematologic malignancies were significantly more likely than those with solid tumors to have intubation and/or mechanical ventilation (37.9% vs. 23.5%), intensive care unit admission (21.9% vs. 7.2%), CPR (14.5% vs. 7.7%), hemodialysis (13.2% vs. 3.1%) or extra-corporeal membrane oxygenation (2.5% vs. 0.4%) in their last 30 days, or intravenous chemotherapy (47.8% vs. 18.4%; all P < .01) within their last 14 days of life. Over 90% of children with hematological malignancies received a blood transfusion within the last 7 days of life. For hematological malignancies, age under 5 years was associated with CPR and ≥ 2 intensive EOLC indicators. Longer hospital stays had decreased odds of ≥ 2 intensive EOLC indicators. Conclusion Children with hematologic malignancies are more likely to receive intensive EOLC compared to those with solid tumors. A younger age and shorter hospital stay might be associated with intensive EOLC in children with hematologic malignancies.
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Affiliation(s)
- Nobuyuki Yotani
- Department of Palliative Medicine, National Centre for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, Japan.
| | - Daisuke Shinjo
- Department of Information Technology and Management, National Centre for Child Health and Development, Tokyo, Japan
| | - Motohiro Kato
- Children's Cancer Center, National Centre for Child Health and Development, Tokyo, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Centre for Child Health and Development, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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11
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Cripe LD, Cottingham AH, Martin CE, Hoffmann ML, Sargent K, Baker LB. Bereaved Informal Caregivers Rarely Recall a Relationship Between Transfusions and Hospice in Acute Myeloid Leukemia. Am J Hosp Palliat Care 2021; 39:68-71. [PMID: 33926274 DOI: 10.1177/10499091211013290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AIMS The inability to prescribe blood transfusions is a potential barrier to timely hospice enrollment for patients with blood cancers. The benefits and harms of transfusions near the end of life (EOL), however, are poorly characterized and patients' preferences are unknown. We sought to characterize the recollections of bereaved caregivers about the relationships between transfusions and hospice enrollment decisions. METHODS We recruited 18 bereaved caregivers of 15 decedents who died within 6-18 months of the interview. Interviews focused on caregivers' recollections of transfusion and hospice enrollment decisions. Transcripts were analyzed for themes. RESULTS We identified 2 themes. First, caregivers described that transfusions were necessary and the decisions to receive transfusions or not were deferred to the clinicians. Second, only 1 caregiver recalled transfusions as relevant to hospice decisions. In that instance there was a delay. Caregivers identified difficulties recognizing death was imminent, hope for miracles, and the necessity of accepting life was ending as more relevant barriers. CONCLUSIONS The results indicate clinicians' beliefs in transfusion at EOL may be a more relevant barrier to hospice enrollment than patients' preferences. Strategies to evaluate accurately and discuss the actual benefits and harms of transfusions at the EOL are necessary to advise patients and integrate their preferences into decisions.
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Affiliation(s)
- Larry D Cripe
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Caroline E Martin
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mary Lynn Hoffmann
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | - Katherine Sargent
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | - Layla B Baker
- 50826The Regenstrief Institute, Indianapolis, IN, USA
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12
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Booker R, Dunn S, Earp MA, Sinnarajah A, Biondo PD, Simon JE. Perspectives of hematology oncology clinicians about integrating palliative care in oncology. Curr Oncol 2020; 27:313-320. [PMID: 33380863 PMCID: PMC7755435 DOI: 10.3747/co.27.6305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Patients with hematologic malignancies receive palliative care (pc) less frequently and later than patients with solid tumours. We compared survey responses of hematology oncology clinicians with other oncology clinicians to better understand their challenges with providing primary pc or using secondary pc. Patients' negative perceptions of pc and limited time or competing priorities were challenges for all clinicians. Compared with other oncology clinicians, more hematology oncology clinicians perceived pc referral criteria as too restrictive (40% vs. 22%, p = 0.021) and anticipated that integrating pc supports into their practice would require substantial change (53% vs. 28%, p = 0.014). This study highlights barriers that may need targeted interventions to better integrate pc into the care of patients with hematologic malignancies.
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Affiliation(s)
- R Booker
- Department of Psychosocial Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - S Dunn
- Department of Community Health Sciences, University of Calgary, Calgary, AB
| | - M A Earp
- Department of Oncology, University of Calgary, Calgary, AB
| | - A Sinnarajah
- Department of Community Health Sciences, University of Calgary, Calgary, AB
- Department of Oncology, University of Calgary, Calgary, AB
- Department of Family Medicine, University of Calgary, Calgary, AB
| | - P D Biondo
- Department of Oncology, University of Calgary, Calgary, AB
| | - J E Simon
- Department of Community Health Sciences, University of Calgary, Calgary, AB
- Department of Oncology, University of Calgary, Calgary, AB
- Department of Medicine, University of Calgary, Calgary, AB
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13
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Moracchini J, Godard-Marceau A, Aubry R. [Study of representations of end-of-life platelet transfusion by its protagonists: Patients, nurses and hematologic oncologists]. Bull Cancer 2020; 107:1241-1251. [PMID: 33092818 DOI: 10.1016/j.bulcan.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/07/2020] [Accepted: 08/14/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION End-of-life platelet transfusion practice in onco-hematology is subjective and depends on representations shared by patients, nurses and hematologists. This study aims to describe these representations of platelet transfusion in a context of a severe and advanced hematologic malignancy through the social representation of its protagonists. METHODS A qualitative study, using the associative network method and including three groups of 15 participants (patients with an advanced hematologic malignancy, regularly transfused in platelet concentrates; nurses and hematologic oncologists) from four hematology centers was conducted between February and April 2019. Analysis was carried out using IraMuTeQ software. RESULTS Patients expect platelet transfusion to have a direct beneficial impact on their health and highlight human relations. Nurses aim at the patient's well-being, in his or her individuality, and at respecting the transfusion protocol. Physicians seek to relieve symptoms by taking into account a multitude of decision-making factors. The textual clustering method, nuances those previous results and individualizes four different orientations, independent of groups: dependency, singularity, subjectivity and neutrality. DISCUSSION The perception of the social representations related to platelet transfusion at the end-of-life should make it possible to adapt the discourse to the preferred orientation of the speaker and could be an asset in goals of care discussion with patients as well as with teams in charge of palliative care.
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Affiliation(s)
- Julie Moracchini
- Centre hospitalier universitaire de Besançon, service d'hématologie, 2, boulevard Fleming, 25000 Besançon, France; Centre hospitalier universitaire de Besançon, centre d'investigation clinique, Inserm CIC1431, 2, place Saint-Jacques, 25030 Besançon cedex, France.
| | - Aurélie Godard-Marceau
- Centre hospitalier universitaire de Besançon, centre d'investigation clinique, Inserm CIC1431, 2, place Saint-Jacques, 25030 Besançon cedex, France
| | - Régis Aubry
- Centre hospitalier universitaire de Besançon, centre d'investigation clinique, Inserm CIC1431, 2, place Saint-Jacques, 25030 Besançon cedex, France; Centre hospitalier universitaire de Besançon, service de soins palliatifs, 2, boulevard Fleming, 25000 Besançon, France
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14
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Sharplin K, Wee LYA, Singhal D, Edwards S, Danner S, Lewis I, Thomas D, Wei A, Yong ASM, Hiwase DK. Outcomes and health care utilization of older patients with acute myeloid leukemia. J Geriatr Oncol 2020; 12:243-249. [PMID: 32713804 DOI: 10.1016/j.jgo.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/27/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The incidence of acute myeloid leukemia (AML) in older patients is increasing, but practice guidelines balancing quality-of-life, time outside of hospital and overall survival (OS) are not established. METHODS We conducted a retrospective analysis comparing time outside hospital, OS and end-of-life care in AML patients ≥60 years treated with intensive chemotherapy (IC), hypomethylating agents (HMA) and best supportive care (BSC) in a tertiary hospital. RESULTS Of 201 patients diagnosed between 2005 and 2015, 54% received IC while 14% and 32% were treated with HMA and BSC respectively. Median OS was significantly higher in patients treated with IC and HMA compared with BSC (11.5 versus 16.2 versus 1.3 months; p < .0001). Median number of hospital admissions for the entire cohort was 3 (1-17) and patients spent <50% of their life after the diagnosis in the hospital setting. Compared to BSC, IC (HR 0.27, p < .0001) and HMA therapy (HR 0.16, p < .0001) were associated with the lower likelihood of spending at least 25% of survival time in hospital. Although 66% patients were referred to palliative care, the interval between referral to death was 24 (1-971) days and 46% patients died in the hospital. CONCLUSION Older patients with AML, irrespective of treatment, require intensive health care resources, are more likely to die in hospital and less likely to use hospice services. Older AML patients treated with disease modifying therapy survive longer than those receiving BSC, and spend >50% of survival time outside the hospital. These data are informative for counselling older patients with AML.
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Affiliation(s)
- Kirsty Sharplin
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia
| | - Li Yan A Wee
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Deepak Singhal
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Suzanne Edwards
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Silke Danner
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia
| | - Ian Lewis
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Daniel Thomas
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Andrew Wei
- Department of Clinical Hematology, Alfred Hospital and Monash University, Melbourne, Australia
| | - Agnes S M Yong
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Devendra K Hiwase
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia.
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15
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Specific challenges in end-of-life care for patients with hematological malignancies. Curr Opin Support Palliat Care 2019; 13:369-379. [DOI: 10.1097/spc.0000000000000470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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16
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Abstract
PURPOSE OF REVIEW The palliative care population is a complex and heterogeneous one. While transfusion therapy is a readily available intervention for many patients, inadequate knowledge for accurately identifying which patient subsets at end-of-life will benefit from a transfusion, along with an unclear understanding of the magnitude of attendant risks of transfusion in those receiving palliative care, complicates the risk-benefit assessment of this therapy. In this brief review, the current literature surrounding transfusion of red cells and platelets in the palliative care patient population will be reviewed and recommendations provided. RECENT FINDINGS Benefits of transfusion therapy include subjective relief of fatigue and dyspnea, and improved sense of wellness, amongst other findings. However, these responses are not durable and there are currently no validated, objective metrics that correlate with symptomatic improvements. It is clear that transfusion-associated adverse reactions are underestimated in those receiving palliative care, with reaction rates similar to the general patient population. Additionally, based on the high mortality rates reported soon after transfusion, the impact of these blood components must be considered as an exacerbating or causative factor of mortality when evaluating declining condition or death. Hematinics are rarely assessed in anemic palliative care patients or, when measured, are often not corrected. The decision to transfuse palliative care patients is multifactorial, and benefits, risks, patient wishes, blood component inventories, and alternatives to transfusion should all be considered. There are many unknowns regarding transfusion in palliative care. Critical next steps for optimizing blood component therapy in this population include high-quality trials that help to identify validated measures of objective functional changes that parallel patient-reported outcomes and subsets of patients receiving end-of-life care that will most likely be positively impacted by transfusion therapy.
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Affiliation(s)
- Jay S Raval
- Department of Pathology, MSC08 4640, University of New Mexico, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
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Sirianni G, Perri G, Callum J, Gardner S, Berall A, Selby D. A Retrospective Chart Review of Transfusion Practices in the Palliative Care Unit Setting. Am J Hosp Palliat Care 2018; 36:185-190. [DOI: 10.1177/1049909118806456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: There remains limited data in the literature on the frequency, clinical utility and effectiveness of transfusions in palliative care, with no randomized controlled trials or clinical practice guidelines on this topic. There are no routinely accepted practices in place for the appropriate transfusion of blood products in this setting. Aim: The aim of this study was to retrospectively review all transfusions in the palliative care units of 2, tertiary care hospitals in Canada. The goals were to elucidate the frequency, indications, patient characteristics, and practices around this intervention. Design: Descriptive, retrospective chart review. Setting/Participants: The clinical charts of patients admitted to the palliative care unit and who obtained blood transfusions for the period of April 1, 2015, to March 31, 2017, were reviewed. All patients admitted who obtained a transfusion were included. There were no exclusion criteria. Results: Transfusions in the palliative care units were rare despite their availability (0.9% at Sunnybrook and 1.4% Baycrest) and were primarily given to patients with cancer. The main symptom issues identified for transfusion were fatigue and dyspnea. The majority of patients endorsed symptomatic benefit with minimal adverse reactions though pre- and post-transfusion assessment practices varied greatly between institutions. Conclusions: Transfusions in the palliative care units were infrequent, symptom targeted, and well tolerated, though the lack of standardized pre/post assessment tools limits any ability to draw conclusions about utility. Patients would benefit from additional research in this area and the development of clinical practice guidelines for transfusions in palliative care.
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Affiliation(s)
- Giovanna Sirianni
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Giulia Perri
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Baycrest Hospital, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Sandra Gardner
- Baycrest Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | | | - Debbie Selby
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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18
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Kirtane K, Downey L, Lee SJ, Curtis JR, Engelberg RA. Intensity of End-of-Life Care for Patients with Hematologic Malignancies and the Role of Race/Ethnicity. J Palliat Med 2018; 21:1466-1471. [PMID: 29975599 DOI: 10.1089/jpm.2018.0152] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Racial/ethnic minority patients with nonhematologic malignancies (non-HM) have lower rates of hospice care, advance directive use, and palliative care utilization than non-Hispanic white (NHW) patients. Less is known regarding racial/ethnic minority patients with hematologic malignancies (HM). OBJECTIVES To study hospital utilization among racial/ethnic minority patients with HM and compare end-of-life outcome measures to patients with non-HM. METHODS We performed a retrospective cohort study (2010-2015) using electronic health records from an integrated academic health center to study differences in hospital utilization patterns and documentation of advance care planning between patients with HM and non-HM. In the subgroup with hematologic malignancy, we examined outcomes associated with racial/ethnic minority status. RESULTS Among all patients in the last 30 days of life, those with HM had higher rates of inpatient care (odds ratio [OR], 1.96; 95% CI: 1.74-2.20; p < 0.001) and intensive care unit (ICU) care (OR, 3.50; 95% CI: 3.05-4.03; p < 0.001). Patients with HM were more likely to die in a hospital (OR, 2.75; 95% CI: 2.49-3.04; p < 0.001) than those with non-HM. Furthermore, during the last 30 days of life, among patients with HM, racial/ethnic minority patients were more likely to have more than one emergency room visit (OR, 6.81; 95% CI: 1.34-33.91; p = 0.02), 14+ days of inpatient care (OR, 1.60; 95% CI: 1.08-2.35; p = 0.02), longer stays in the ICU (OR, 1.26; 95% CI: 1.04-1.52; p = 0.02), and lower rates of advance directive documentation (OR, 0.60; 95% CI: 0.44-0.82; p < 0.01) than NHWs. CONCLUSION Our findings suggest that racial/ethnic minority patients with HM have higher utilization of care at the end-of-life and lower rates of advance directives compared with NHW patients.
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Affiliation(s)
- Kedar Kirtane
- 1 Fred Hutchinson Cancer Research Center, University of Washington , Seattle, Washington
| | - Lois Downey
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,3 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Stephanie J Lee
- 4 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - J Randall Curtis
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,3 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,3 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
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19
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Beaussant Y, Daguindau E, Chauchet A, Rochigneux P, Tournigand C, Aubry R, Morin L. Hospital end-of-life care in haematological malignancies. BMJ Support Palliat Care 2018; 8:314-324. [PMID: 29434048 DOI: 10.1136/bmjspcare-2017-001446] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate patterns of care during the last months of life of hospitalised patients who died from different haematological malignancies. METHODS Nationwide register-based study, including all hospitalised adults ≥20 years who died from haematological malignancies in France in 2010-2013. Outcomes included use of invasive cancer treatments and referral to palliative care. Percentages are adjusted for sex and age using direct standardisation. RESULTS Of 46 629 inpatients who died with haematological malignancies, 24.5% received chemotherapy during the last month before death, 48.5% received blood transfusion, 12.3% were under invasive ventilation and 18.1% died in intensive care units. We found important variations between haematological malignancies. The use of chemotherapy during the last month of life varied from 8.6% among patients with chronic myeloid leukaemia up to 30.1% among those with non-Hodgkin's lymphoma (P<0.001). Invasive ventilation was used in 10.2% of patients with acute leukaemia but in 19.0% of patients with Hodgkin's lymphoma (P<0.001). Palliative status was reported 30 days before death in only 14.8% of patients, and at time of death in 46.9% of cases. Overall, 5.5% of haematology patients died in palliative care units. CONCLUSION A high proportion of patients who died from haematological malignancies receive specific treatments near the end of life. There is a need for a better and earlier integration of the palliative care approach in the standard practice of haematology. However, substantial variation according to the type of haematological malignancy suggests that the patients should not be considered as one homogeneous group. Implementation of palliative care should account for differences across haematological malignancies.
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Affiliation(s)
- Yvan Beaussant
- Department of Palliative Care, Besancon University Hospital, Besançon, France.,Inserm CIT808, Besancon University Hospital, Besancon, France
| | - Etienne Daguindau
- Hematology Department, Besancon University Hospital, Besancon, France
| | - Adrien Chauchet
- Hematology Department, Besancon University Hospital, Besancon, France
| | - Philippe Rochigneux
- Department of Medical Oncology, Paoli-Calmettes Cancer Institute, Marseille, France
| | - Christophe Tournigand
- Department of Medical Oncology, Hopital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France.,Paris-Est Creteil University, Créteil, France
| | - Régis Aubry
- Department of Palliative Care, Besancon University Hospital, Besançon, France.,Inserm CIT808, Besancon University Hospital, Besancon, France
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
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20
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Lowe JR, Yu Y, Wolf S, Samsa G, LeBlanc TW. A Cohort Study of Patient-Reported Outcomes and Healthcare Utilization in Acute Myeloid Leukemia Patients Receiving Active Cancer Therapy in the Last Six Months of Life. J Palliat Med 2018; 21:592-597. [PMID: 29341836 DOI: 10.1089/jpm.2017.0463] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Evidence about the unique palliative care needs of patients with acute myeloid leukemia (AML) is limited. Improving the care of these patients will require a better understanding of their unmet needs, including symptom burden at the end of life, and patterns of healthcare utilization. OBJECTIVE To describe AML patients' experiences in the last six months of life regarding symptom burden, blood product utilization, and use of palliative care services. METHODS Exploratory analysis of prospectively collected patient-reported outcomes and healthcare utilization data during the last six months of life among 33 AML patients who died during a longitudinal observational study. RESULTS Symptom burden, quality of life (QOL), and psychological distress worsened with proximity to death. Of the 26 patients with utilization data, most (n = 24; 92.4%) were hospitalized in the last month of life, with 26.9% (n = 7) dying in the intensive care unit. Patients required a median of 16 red blood cell transfusions in the last six months of life, and those with a high transfusion burden in the last month of life had a higher rate of in-hospital death (blood transfusions: p < 0.01; platelet transfusions: p = 0.03). Only six patients enrolled in hospice (23.1%). DISCUSSION Patients with AML have marked symptoms and QOL impairments that escalate in the final six months of life. Patients entering the healthcare system for active cancer treatment are likely to continue disease-oriented care until death. High rates of hospitalization and blood product transfusion are a direct barrier to transitioning to hospice care.
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Affiliation(s)
- Jared R Lowe
- 1 Department of Medicine, Duke University School of Medicine , Durham, North Carolina
| | - Yinxi Yu
- 2 Department of Biostatistics and Bioinformatics, Duke University School of Medicine , Durham, North Carolina
| | - Steven Wolf
- 2 Department of Biostatistics and Bioinformatics, Duke University School of Medicine , Durham, North Carolina
| | - Greg Samsa
- 2 Department of Biostatistics and Bioinformatics, Duke University School of Medicine , Durham, North Carolina
| | - Thomas W LeBlanc
- 3 Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine , Durham, North Carolina
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21
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Hochman MJ, Yu Y, Wolf SP, Samsa GP, Kamal AH, LeBlanc TW. Comparing the Palliative Care Needs of Patients With Hematologic and Solid Malignancies. J Pain Symptom Manage 2018; 55:82-88.e1. [PMID: 28887271 PMCID: PMC5921902 DOI: 10.1016/j.jpainsymman.2017.08.030] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT Hematologic cancer patients use palliative care services less frequently than their solid tumor counterparts. Prior work suggests that these patients have a sizable symptom burden, but comparisons between hematologic and solid tumor patients near the end of life are limited. OBJECTIVES To compare unmet symptom needs in a cohort of hematologic and solid tumor patients referred to specialty palliative care services. METHODS Using a novel data registry of initial palliative care encounters, we performed a cross-sectional analysis of cancer patients receiving care across 17 sites within the Global Palliative Care Quality Alliance. We compared clinically-significant symptoms (rated as four or greater in severity) between hematologic and solid tumor patients and performed multivariate logistic regression analyses examining the relationship between symptom burden and tumor type. RESULTS We identified 1235 cancer patients, 108 of which had hematologic malignancies. Pain, dyspnea, nausea, and anorexia burden were as high among patients with hematologic as those with solid malignancies. Blood cancer patients had higher rates of clinically-significant tiredness (51% vs. 42%; P = 0.03) than solid tumor patients. Finally, blood cancer patients had greater odds of being tired (odds ratio 2.19; CI 1.22-3.91) and drowsy (odds ratio 1.81; CI 1.07-3.07) than solid tumor patients independent of age, gender, race, and performance status. CONCLUSIONS Hematologic and solid tumor patients have significant symptom burden at time of referral to palliative care services. Blood cancer patients may have unique concerns warranting targeted attention, including substantial drowsiness and tiredness. Our findings suggest a need to optimize palliative care usage in the hematologic cancer population.
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Affiliation(s)
| | - Yinxi Yu
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven P Wolf
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Greg P Samsa
- Duke Biostatistics Core, Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Fuqua School of Business, Duke University, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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22
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Wang WS, Ma JD, Nelson SH, Revta C, Buckholz GT, Mulroney C, Roeland EJ. Transfusion practices at end of life for hematopoietic stem cell transplant patients. Support Care Cancer 2017; 26:1927-1931. [PMID: 29285557 DOI: 10.1007/s00520-017-4023-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Limited data exist regarding transfusion practices at end of life (EOL) for hematopoietic stem cell transplant (HSCT) patients. The purpose of this study was to examine red blood cell (RBC) and platelet transfusion practices in HSCT patients who enrolled or did not enroll in hospice. METHODS This was a single-center, retrospective chart review in deceased HSCT patients. The primary objective was to determine the mean difference between the last transfusion and death in HSCT patients (n = 116) who enrolled or did not enroll in hospice. RESULTS Sixteen (14%) and 100 (86%) patients were enrolled in hospice and not enrolled in hospice, respectively. Hospice patients observed a larger mean difference between death and last transfusion (45.9 ± 66.7 vs. 14.6 ± 48.1 days, p < 0.0001). A higher amount of platelet, but not RBC, transfusions occurred in patients not enrolled in hospice (p = 0.04). The last transfusion that occurred more than 96 h before death was observed in 12 (75%) and 22 (22%) in hospice and non-hospice patients, respectively. For HSCT patients not enrolled in hospice, 17 patients received a transfusion on the same day of death and 31 patients received the last transfusion 24 h before death. CONCLUSIONS Blood transfusion practices differed in HSCT patients enrolled and not enrolled in hospice. For most patients not enrolled in hospice, the last transfusion occurred 24 h before death. Future efforts should explore if limited access to blood products is a barrier to hospice enrollment for HSCT patients.
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Affiliation(s)
- Winnie S Wang
- Internal Medicine, University of California (UC), San Diego, San Diego, CA, USA
| | - Joseph D Ma
- Skaggs School of Pharmacy & Pharmaceutical Sciences, UC San Diego, La Jolla, CA, USA
| | - Sandahl H Nelson
- Department of Cancer Prevention and Control, UC San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Carolyn Revta
- Division of Hematology/Oncology, Doris A. Howell Palliative Care Service, UC San Diego Moores Cancer Center, 3855 Health Sciences Drive, MC 0987, La Jolla, CA, 92093, USA
| | - Gary T Buckholz
- Division of Hematology/Oncology, Doris A. Howell Palliative Care Service, UC San Diego Moores Cancer Center, 3855 Health Sciences Drive, MC 0987, La Jolla, CA, 92093, USA
| | - Carolyn Mulroney
- Blood and Marrow Transplant, UC San Diego Moores Cancer Center, La Jolla, CA, USA
| | - Eric J Roeland
- Division of Hematology/Oncology, Doris A. Howell Palliative Care Service, UC San Diego Moores Cancer Center, 3855 Health Sciences Drive, MC 0987, La Jolla, CA, 92093, USA.
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Advance care planning and end-of-life care for patients with hematologic malignancies who die after hematopoietic cell transplant. Bone Marrow Transplant 2017; 52:929-931. [PMID: 28287642 DOI: 10.1038/bmt.2017.41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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