Palliative care for patients with hematological malignancies-a case series

Prognostic factors in patients in the terminal phase of haematological malignancies who are receiving home medical care

Although there are many prognostic models for patients in the terminal phase of solid tumours, a reliable prognostic scoring system in patients in the terminal phase of haematological malignancies (HM) has not been established. We retrospectively evaluated 180 patients in the terminal phase of HM who were receiving home medical care (HMC). Multivariate analyses revealed that clinician's estimate, consciousness, loss of appetite, dyspnoea, neutrophil count, lymphocyte count, and lactate dehydrogenase were associated with overall survival (OS). Based on this result, we developed a novel prognostic scoring system, the Japan palliative haematological oncology prognostic estimates, in which four risk groups were shown to clearly differ in survival (p < 0.001): a low-risk group (n = 41, median OS of 434 days), an intermediate-low-risk group (n = 80, median OS of 112 days), an intermediate-high-risk group (n = 38, median OS of 31.5 days), and a high-risk group (n = 21, median OS of 10 days). This is the first investigation of prognostic factors that influence the OS of patients in the terminal phase of HM who are receiving HMC. Providing patients with reliable information about their prognosis is important for them to consider how to spend their remaining life.

Intensive end-of-life care in acute leukemia from a French national hospital database study (2017–2018)

Background

A better understanding of how the care of acute leukemia patients is managed in the last days of life would help clinicians and health policy makers improve the quality of end-of-life care. This study aimed: (i) to describe the intensity of end-of-life care among patients with acute leukemia who died in the hospital (2017–2018) and (ii) to identify the factors associated with the intensity of end-of-life care.

Methods

This was a retrospective cohort study of decedents based on data from the French national hospital database. The population included patients with acute leukemia who died during a hospital stay between 2017 and 2018, in a palliative care situation (code palliative care Z515 and-or being in a inpatient palliative care support bed during the 3 months preceding death). Intensity end-of-life care was assessed using two endpoints: High intensive end-of-life (HI-EOL: intensive care unit admission, emergency department admission, acute care hospitalization, intravenous chemotherapy) care and most invasive end-of-life (MI-EOL: orotracheal intubation, mechanical ventilation, artificial feeding, cardiopulmonary resuscitation, gastrostomy, or hemodialysis) care.

Results

A total of 3658 patients were included. In the last 30 days of life, 63 and 13% of the patients received HI-EOL care and MI-EOL care, respectively. Being younger, having comorbidities, being care managed in a specialized hospital, and a lower time in a palliative care structure were the main factors associated with HI-EOL.

Conclusions

A large majority of French young adults and adults with acute leukemia who died at the hospital experienced high intensity end-of-life care. Identification of factors associated with high-intensity end-of-life care, such as the access to palliative care and specialized cancer center care management, may help to improve end-of-life care quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00937-0.

Prospective observational study of palliative care in hematological malignancies: Report of one year of practice

INTRODUCTION

Palliative care is an approach that improves the quality of life of patients with advanced disease.

OBJECTIVE

The aim of this study is to evaluate the process of palliative care in patients with hematologic malignancies.

METHODS

In this prospective observational study, we included patients with hematologic malignancies who received palliative care over a 12 month period from June 1, 2019, to May 31, 2020 at the day care hospital of the hematology department in University Hospital of Sfax, Tunisia. Blood transfusion was used to relieve symptoms of anemia and bleeding.

RESULTS

Fifty-five patients were included. The median age was 68 years. Forty-three percent of patients were diagnosed with acute leukemia and 41.8% with myelodysplastic syndrome. Red cell and platelet transfusions were indicated in 94.5% and 36.3% of cases respectively. Patients reported improvement after blood transfusion in 50% of cases. Twenty-five transfusion reactions (45%) were noted. Fever was noted in 33 patients (60%), with documented sites of infection in 84.8% of them. Pulmonary infection was frequently noted (50%). Antimicrobial treatment was prescribed in all febrile cases. Pain was reported in 22 patients and in 77.5% of these cases, it was nociceptive. Patients who received analgesics showed clinical improvement in pain in 81% of cases. Anorexia with malnutrition was reported in 23% of cases which was treated with enteral nutrition in 75% of cases. Sleep disturbance (20 patients), anxiety (7 patients), and depression (4 patients) were mentioned respectively.

CONCLUSION

Palliative care in hematology should be a multidisciplinary care approach with a global management of the various physical, psychological and sociological complications.

Palliative care in onco-hematology: a perspective

Palliative care (PC) is focused on individualized symptomatic control, psychological help, and support in the context of severe disease. Oncologic patients are still the most referred to PC and hematologic patients are only 7%. This is a commentary about PC applied to hematologic patients. There is evidence supporting that these patients behave as a special group in PC when compared with other tumors: there is a smaller number of referrals, with more advanced disease status, more symptomatology expressed, and less time between the last treatment date and the referral date or death. This article also expresses the experience of an oncologic palliative care unit. More health education programs in PC are needed for specialized professionals in hematology, as well as a change of nowadays health politics, in order to increase the participation of this specialized care in hematology.

The profile of the onco-hematology patient in the palliative care: 4 years of experience

Objectives:

Most of the palliative care (PC) patients have oncologic diseases, being hematologic tumors a small part of them. According to the literature, onco-hematologic (OH) patients should be individualized from those with solid tumors for the specialized care required along their disease course. This study aims to review the casuistry of OH patients referred to PC in a specialized oncologic hospital and help to understand better how hematologists can improve the care of these patients.

Methods:

We analyzed all OH patients referred to the PC service in 1 oncologic hospital along 42 months, through consultation of their clinical files.

Results:

A total of 179 patients were reviewed (52.% males, median age of 71 years): 48.6% had non-Hodgkin lymphoma, 26.3% had multiple myeloma, 10.6% had acute leukemia, 14.5% had other OH diseases; 88.2% were treated for their OH disease (96.2% with chemotherapy, 28.5% radiotherapy, and 21.5% hematopoietic stem cell transplant). The referral was heterogeneous among physicians (27.4% by 1 physician). Most patients were firstly observed as inpatients (55.3%) and 17.9% in the outpatient consult. At the end of the study, 98.9% of the patients died (88.7% in the hospital, 10.2% at home). The median time between the end of treatment and referral do PC was 46 days and between referral and death was 16 days. We also reviewed medical prescription in the last month of life and we noticed that most invasive orders were requested by hematologists (as antibiotic prescription, imaging, and biopsy studies).

Significance of results:

This study demonstrated that OH patients should be referred earlier to PC and that a more intensive team work needs to be practiced between PC and hematologists. More educational programs for healthcare workers on this issue are needed in order to guarantee a more effective assistance in the appropriate time.

Space for intuition - the 'Surprise'-Question in haemato-oncology: Qualitative analysis of experiences and perceptions of haemato-oncologists

BACKGROUND

Early integration of palliative care can improve outcomes for people with cancer and non-cancer diagnoses. However, prediction of survival for individuals is challenging, in particular in patients with haematological malignancies who are known to have limited access to palliative care. The 'Surprise'-Question can be used to facilitate referral to palliative care.

AIM

To explore experiences, views and perceptions of haemato-oncologists on the use of the 'Surprise'-Question in the haemato-oncology outpatients clinics of a university hospital in Germany.

DESIGN

A qualitative study using individual semi-structured interviews transcribed verbatim and analysed thematically based on the framework approach.

SETTING/PARTICIPANTS

The study took place at the haemato-oncology outpatient clinic and the bone marrow transplantation outpatient clinic of a university hospital. Nine haemato-oncologists participated in qualitative interviews.

RESULTS

Thematic analysis identified 4 themes and 11 subthemes: (1) meaning and relevance of the 'Surprise'-Question; (2) feasibility; (3) the concept of 'surprise' and (4) personal aspects of prognostication. A key function of the 'Surprise'-Question was to stimulate intuition and promote patient-centred goals of care by initiating a process of pause → reflection → change of perspective. It was easy and quick to use, but required time and communication skills to act on. Participants' training in palliative care enhanced their willingness to use the 'Surprise'-Question.

CONCLUSION

Irrespective of its use in prognostication, the 'Surprise'-Question is a valuable tool to facilitate consideration of patient-centred goals and promote holistic care in haemato-oncology. However, prognostic uncertainty, lack of time and communication skills are barriers for integration into daily practice. Further research should involve haematology patients to integrate their needs and preferences.

Hospital end-of-life care in haematological malignancies

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.

Improving the Transition to Palliative Care for Patients With Acute Leukemia: A Coordinated Care Approach

BACKGROUND

Currently, there is little guidance available for documenting and executing the change in management goals in the context of incurable hematologic disease.

OBJECTIVE

The aim of this study was to improve the transition to palliative care for patients with acute myeloid leukemia (AML) through the development and implementation of a coordinated care plan program.

METHODS

Twenty-three patients with AML who were no longer being treated with curative intent from March 2011 through September 2012 had hematology supportive care plans developed. Patients (n = 7) completed post-care plan implementation questionnaires to determine their level of understanding in relation to the change in treatment intent. Staff completed pre- (n = 26) and post- (n = 19) care plan implementation questionnaires to determine the communication, challenges, and accessibility of changed management goals.

RESULTS

Seventy-seven percent of patients understood palliative care to be the primary team managing their symptoms, with 75% of patients viewing symptom control as the main goal of treatment. Staff findings demonstrated a significant improvement in the communication of treatment goals (53% preimplementation vs 86% postimplementation). Early timing of referrals remains a significant issue.

CONCLUSIONS

Implementing the individualized care plan program was associated with better communication and accessibility of documented palliative treatment goals for patients with AML.

IMPLICATIONS FOR PRACTICE

This study establishes a model of care that addresses symptom and disease burden in end-stage AML and provides valuable insight into the patient and family understanding of treatment intent during this terminal phase.

Palliative home care for patients with advanced haematological malignancies-a multicenter survey

Patients with advanced haematological malignancies in non-curative settings suffer from complex physical symptoms and psychosocial distress, comparable to patients with solid tumour entities. Nevertheless, numerous problems at the interface between haematology and palliative home care have been described. From January 2011 until October 2014, we performed a retrospective, multicenter analysis of all patients with haematological malignancies (ICD 10: C81-C95) being treated by the respective specialized palliative home care (SAPV) team. Three SAPV teams were surveyed. Disease entity, physical symptoms, psychosocial distress, number of hospital admissions, therapeutic interventions and other items were analysed descriptively. Of 3,955 SAPV patients, 1.8% (n = 73) suffered from haematological malignancies. Main problems were deterioration of general condition, pain or psychological problems. Thirty-seven percent developed new symptoms during SAPV, mainly pain, psychological distress or deterioration of general status. In 33%, patients were referred to hospital, mainly due to deterioration of general condition or pain. Seventy percent died within 3 months after beginning SAPV care; 83% died at home or in a nursing home. Patients suffering from advanced haematological malignancies were statistically underrepresented in SAPV, and SAPV was installed rather at the very last days of life. By far, more patients were able to die outside a hospital as compared to reference cohorts of haematological patients not being treated in SAPV. The spectrum of documented problems is comparable to other patient cohorts being treated in SAPV; therefore, the options and benefits of palliative home care should be incorporated in palliative haematological treatment concepts more vigorously and consequently.

Barriers to the Collaboration Between Hematologists and Palliative Care Teams on Relapse or Refractory Leukemia and Malignant Lymphoma Patients’ Care

Background:

Palliative care service (PCS) has been shown to be utilized less in patients with leukemia and malignant lymphoma than in those with solid tumors. Previous studies have suggested hematologists’ limited awareness of PCS as one of the reason for low PCS referral in hematology. However, little is known about such an awareness and potential barriers to collaboration between hematologists and PCS.

Aim:

The present study aimed to assess ematologists and palliative care specialists’ perception about the roles of the hospital-based palliative care team (HPCT) and the barriers to collaboration between hematologists and palliative care teams on relapse or refractory leukemia and malignant lymphoma patients’ care

Materials and Methods:

A qualitative study was conducted using semistructured interviews with hematologists and palliative care specialists recruited from a hospital that provides hematology and palliative care by the HPCT. Data were evaluated via content analysis.

Results:

The study included 11 hematologists and 10 palliative care specialists. Our results revealed that they shared many common perceptions about the roles and expectations of the HPCT. Additionally, 7 categories of barriers to collaboration were identified, including not feeling the need to refer, the difficulty in referral timing, the lack of aggressive approach, the negative image of the HPCT, the need for hematologic malignancy-oriented management, the lack of communication, and others.

Conclusion:

We have identified hematologists’ and palliative care specialists’ perceptions of the HPCT’s roles and the barriers to their collaboration. A better understanding of such barriers may lead to effective collaboration between hematologists and the HPCT.

Perceptions of palliative care among hematologic malignancy specialists: a mixed-methods study

PURPOSE

Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood.

METHODS

This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences.

RESULTS

Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care.

CONCLUSION

Most hematologic oncologists view palliative care as end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists.

[Pain therapy in oncology: results of a nationwide survey]

BACKGROUND

Pain is one of the most prevalent and distressing symptoms of patients suffering from cancer. In the field of oncology comprehensive expertise is pursued not only with respect to the administration of anticancer treatment but to all fields that relate to the needs of cancer patients. However, the results of studies have revealed persisting and relevant deficits in pain therapy in the setting of oncology.

MATERIALS AND METHODS

An online survey was performed involving all members of the German Society for Hematology and Medical Oncology (DGHO) with respect to training and continuing education in pain therapy, the relevance for routine oncology and knowledge, to determine the level of expertise in pain therapy and the assessment of tumor-specific therapy.

RESULTS

A total of 183 out of 1,962 questionnaires could be evaluated. Oncologists are often engaged in pain therapy and 80 % of the respondents perceived themselves as being primarily responsible for pain control. Education and assessment were identified as barriers to sufficient pain therapy. Case vignettes revealed only few relevant therapeutic misinterpretations.

CONCLUSION

This first survey of German oncologists exploring expertise in cancer pain therapy, showed similar problems in education and pain assessment as previous international studies. Despite the claimed responsibility for pain management, there were a small but relevant number of oncologists who showed serious therapeutic misinterpretations in case studies.