Characteristics and course of patients with advanced hematologic malignancies receiving specialized inpatient palliative care at a German university hospital

Hospital Palliative Care Team Involvement in Inpatients with Hematologic Malignancies: A Retrospective Study

Background: Data on the involvement of hospital palliative care teams (HPCT) in the management of patients with hematologic malignancies (HM) are limited. Objectives: To describe characteristics, symptom burden according to the German Hospice and Palliative Care Evaluation assessment tool, and course of inpatients with HM who were referred to a HPCT, and compare them with their counterparts with solid tumors (ST). Design: Retrospective analysis. Setting/Subjects: Inpatients with HM and ST who were referred to the HPCT of a comprehensive cancer center in Germany between January 1, 2015, and December 31, 2019. Results: The analysis included 2885 patients; 412 (14.3%) had HM and 2473 (85.7%) had ST. Patients with HM more often experienced depression (p = 0.003), tension (p < 0.001), and disorientation (p = 0.003); pain (p = 0.029), nausea (p = 0.003), weakness (p < 0.001), loss of appetite (p = 0.005), tiredness (p < 0.001), and need for assistance with activities of daily living (p < 0.001) were more common in patients with ST. Patients with HM were more often admitted to the intensive care unit (ICU) (p < 0.001), had longer ICU stays (p = 0.005), and had a higher death rate (p < 0.001) during their last stay in the hospital. The time between the first contact with the HPCT and death was shorter for patients with HM (p < 0.001). Patients with HM also had a shorter overall time of care by the HPCT (p < 0.001). Conclusions: As compared with their counterparts with ST, inpatients with HM were closer to death at referral to the HPCT, experienced a comparable overall symptom burden, and were admitted to the ICU more frequently after HPCT involvement.

Utilization and quality of palliative care in patients with hematological and solid cancers: a population-based study

BACKGROUND

Palliative care (PC) contributes to improved end-of-life care for patients with hematologic malignancies (HM) and solid tumors (ST) by addressing physical and psychological symptoms and spiritual needs. Research on PC in HM vs. ST patients is fragmented and suggests less use.

METHODS

We analyzed claims data of all deceased members of a large German health insurance provider for the year before death. First, we analyzed the frequency and the beginning of different types of PC and compared patients with HM vs. ST. Second, we analyzed the adjusted impact of PC use on several end-of-life quality outcomes in patients with HM vs. ST. We performed simple and multiple (logistic) regression analysis, adjusted for relevant covariates, and standardized for age and sex.

RESULTS

Of the 222,493 deceased cancer patients from 2016 to 2020, we included 209,321 in the first analysis and 165,020 in the second analysis. Patients with HM vs. ST received PC less often (40.4 vs. 55.6%) and later (34 vs. 50 days before death). PC use significantly improved all six quality indicators for good end-of-life care. HM patients had worse rates in five of the six indicators compared with ST patients. Interaction terms revealed that patients with ST derived greater benefit from PC in five of six quality indicators than those with HM.

CONCLUSION

The data highlight the need to integrate PC more often, earlier, and more effectively into the care of patients with HM.

Developing a supportive and palliative care intervention for patients with allogeneic stem cell transplantation: protocol of a multicentre mixed-methods study (allo-PaS)

INTRODUCTION

Although allogeneic stem cell transplantation (allo-SCT) is a curative treatment for many haematological malignancies, it is often associated with a high morbidity and mortality. Yet, little is known about the needs for supportive and palliative care among allo-SCT recipients. Moreover, targeted interventions that reduce symptom burden and suffering are still lacking. The present study aims to inform a supportive-palliative care intervention for patients with allo-SCT and their informal carers by exploring their experience and assessing their needs, especially their existential concerns, regarding four research topics: symptom burden and quality of life; coexistence of a chance for cure and a relevant risk of dying; change in goals of care; dying phase.

METHODS AND ANALYSIS

This is a descriptive mixed-methods study in progress with a convergent parallel design. Data on the four research topics will be collected and analysed separately in three steps: (1) qualitative semi-structured interviews among 20 patients, 20 informal carers and 12 healthcare providers (HCPs) and focus groups among 12-24 HCPs; (2) a quantitative cross-sectional survey with validated questionnaires and self-developed questions among 100 patients, 100 informal carers and 50 HCPs; (3) a retrospective case analysis of all deceased patients who underwent an allo-SCT between 2010 and 2019, with collection of quantitative and qualitative data. The qualitative and quantitative data sets will be finally merged for comparison and interpretation. Results will serve to develop a supportive-palliative care intervention.

ETHICS AND DISSEMINATION

The Ethics Commission of the Faculty of Medicine of the University of Cologne approved this study (20-1370_2). The study results will be published in peer-review journals, be presented at congresses and will be translated into clinical practice through the development of the palliative-supportive care intervention.

TRIAL REGISTRATION NUMBER

DRKS00027290 (German Clinical Trials Register).

Providing Care to People Living with a Chronic Hematological Malignancy: A Qualitative Evidence Synthesis of Informal Carers' Experiences

OBJECTIVE

Chronic hematological malignancies such as multiple myeloma, chronic lymphocytic leukemia (CLL), indolent B-cell lymphomas, and myelodysplastic syndromes (MDS) have seen significant advances in treatment. Treatment developments have resulted in patients living for many years, often between periods of being acutely unwell, relapses, and remission. Informal carers play a major role in supporting patients through the uncertain and long illness trajectory. This qualitative evidence synthesis (QES) aims to synthesize qualitative research evidence on the experiences of informal carers caring for a patient with a chronic hematological malignancy (CHM).

DATA SOURCES

This qualitative evidence synthesis followed the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines and adopted a "best fit" framework synthesis approach using a "redefining normal" conceptual framework. A systematic search of seven databases was undertaken.

CONCLUSION

Sixteen qualitative studies were synthesized in this review. Eight review findings illuminated carers' unmet information needs, challenges with caring responsibilities, end-of-life care, and changes in the dyad carer-patient relationship.

IMPLICATIONS FOR NURSING PRACTICE

This best-fit framework synthesis illuminates the wide-ranging challenges experienced by informal caregivers of people living with a chronic hematological malignancy. Carers' fear for the future highlights the need for interventions to support them with their fears. Carers' priority on their loved one's quality of life is impaired by late end-of-life discussions often not occurring until a sudden deterioration in the patient's condition. Early supportive relationships between carers and health care providers can promote conversations on poor prognosis and end-of-life care. Future research should focus on qualitative longitudinal studies with caregiver-patient dyads.

Palliative care for patients with hematologic malignancies: are we meeting patients' needs early enough?

INTRODUCTION

Palliative care for patients with cancer, and more recently for patients with hematologic malignancies, has increasingly been shown to be beneficial, with mounting evidence pointing to its vast benefits both to patients and caregivers. Despite this, there is a significant gap in integration of palliative care into usual cancer care for patients with hematologic malignancies.

AREAS COVERED

In this paper, we will define palliative care and discuss its benefits broadly for patients with hematologic malignancies. We will then discuss the late access to palliative care, the unmet needs in this patient population, and some of the barriers to access to palliative care.

EXPERT OPINION

With all this information and the clear benefit for early integrated palliative care for patients with hematologic malignancies, there is a need for novel models of palliative care and cancer care integration. Given the various needs of patients with different hematologic malignancies, we propose how palliative care can meet the unique needs of patients with hematologic malignancy by disease subtype.

Perceptions of Hematology Among Palliative Care Physicians: Results of a Nationwide Survey

CONTEXT

Palliative care integration for patients with hematologic diseases has lagged behind solid-organ malignancies. Previous work has characterized hematologist perspectives, but less is known about palliative care physician views of this phenomenon.

OBJECTIVES

To examine palliative care physician attitudes and beliefs regarding hematologic diseases, patient care, and collaboration.

METHODS

A 44-item survey containing Likert and free-response items was mailed to 1000 AAHPM physician members. Sections explored respondent comfort with specific diagnoses, palliative care integration, relationships with hematologists, and hematology-specific patient care. Logistic regression models with generalized estimating equations were used to compare parallel Likert responses. Free responses were analyzed using thematic analysis.

RESULTS

The response rate was 55.5%. Respondents reported comfort managing symptoms in leukemia (84.0%), lymphoma (92.1%), multiple myeloma (92.9%), and following hematopoietic stem cell transplant (51.6%). Fewer expressed comfort with understanding disease trajectory (64.9%, 75.7%, 78.5%, and 35.4%) and discussing prognosis (71.0%, 82.6%, 81.6%, and 40.6%). 97.6% of respondents disagreed that palliative care and hematology are incompatible. 50.6% felt that palliative care physicians' limited hematology-specific knowledge hinders collaboration. 89.4% felt that relapse should trigger referral. 80.0% felt that hospice referrals occurred late. In exploring perceptions of hematology-palliative care relationships, three themes were identified: misperceptions of palliative care, desire for integration, and lacking a shared model of understanding.

CONCLUSION

These data inform efforts to integrate palliative care into hematologic care at large, echoing previous studies of hematologist perspectives. Palliative care physicians express enthusiasm for caring for these patients, desire for improved understanding of palliative care, and ongoing opportunities to improve hematology-specific knowledge and skills.

What is known about palliative care in adult patients with allogeneic stem cell transplantation (allo-SCT)?

Patients undergoing allogeneic stem cell transplantation (allo-SCT) are given a real chance of cure, but at the same time are confronted with a considerable risk of mortality and of severe long-term impediments. This narrative, non-systematic literature review aims to describe the supportive and palliative care needs of allo-SCT recipients, including long-term survivors or those relapsing or dying after transplantation. It also evaluates the feasibility and effectivity of integrating palliative care early in transplant procedures. In this appraisal of available literature, the main findings relate to symptoms like fatigue and psychological distress, which appear to be very common in the whole allo-SCT trajectory and might even persist many years post-transplantation. Chronic GvHD has a major negative impact on quality of life. Overall, there is a paucity of research on further issues in the context of allo-SCT, like the distress related to the frequently unpredictable post-transplant trajectory and prognosis, as well as the end-of-life phase. First randomized controlled results support the effectiveness of early integration of specialized palliative care expertise into transplant algorithms. Barriers to this implementation are discussed.

Early palliative care in haematological patients: a systematic literature review

Background

Early palliative care together with standard haematological care for advanced patients is needed worldwide. Little is known about its effect. The aim of the review is to synthesise the evidence on the impact of early palliative care on haematologic cancer patients’ quality of life and resource use.

Patients and methods

A systematic review was conducted. The search terms were early palliative care or simultaneous or integrated or concurrent care and haematological or oncohaematological patients. The following databases were searched: PubMed, Embase, Cochrane, CINHAL and Scopus. Additional studies were identified through cross-checking the reference articles. Studies were in the English language, with no restriction for years. Two researchers independently reviewed the titles and abstracts, and one author assessed full articles for eligibility.

Results

A total of 296 studies titles were reviewed. Eight articles were included in the synthesis of the results, two controlled studies provided data on the comparative efficacy of PC interventions, and six one-arm studies were included. Since data pooling and meta-analysis were not possible, only a narrative synthesis of the study results was performed. The quality of the two included comparative studies was low overall. The quality of the six non-comparative studies was high overall, without the possibility of linking the observed results to the implemented interventions.

Conclusions

Studies on early palliative care and patients with haematological cancer are scarce and have not been prospectively designed. More research on the specific population target, type and timing of palliative care intervention and standardisation of collected outcomes is required.

PROSPERO registration number

CRD42020141322.

Retrospective review of end-of-life care in the last month of life in older patients with multiple myeloma: what collaboration between haematologists and palliative care teams?

OBJECTIVES

Patients with haematological malignancies (HM) receive more aggressive treatments near the end-of-life (EOL) than patients with solid tumours. Palliative care (PC) needs are less widely acknowledged in patients with multiple myeloma (MM) than in other HM. The main objective of our study was to describe EOL care and PC referral in a population of older patients with MM.

METHODS

We retrospectively included deceased inpatients and outpatients with an MM previously diagnosed at the age of 70 and over in two tertiary centres in France. We reported EOL characteristics regarding treatments considered to be aggressive-antimyeloma therapies, hospitalisations, blood product transfusions, intensive care units (ICUs) or emergency admissions-and PC referral.

RESULTS

We included 119 patients. In their last month of life, 75 (63%) were hospitalised for fever, pain, asthenia, anaemia or bleeding, 49 (41%) were admitted in the emergency department and 12 (10%) in ICU, 76 (64%) still received antimyeloma therapy and 45 (38%) had at least two transfusions. Only 24 (20%) received PC intervention for pain, global care, family support, anxiety, social care or confusion. Median follow-up until death was 20 days.

CONCLUSIONS

Our study found a high rate of hospitalisations and antimyeloma therapies in the last month of life. The PC referral rate was low, often once specific treatments were stopped. Our results suggest the need for more effective collaboration between PC teams and haematologists in order to respond to the specific needs of these patients and to improve their quality of care at EOL.

Palliative Care for Patients With Hematologic Malignancies in a Low-Middle Income Country: Prevalence of Symptoms and the Need for Improving Quality of Attention at the End of Life

BACKGROUND

Palliative care (PC) for patients with malignant hematological diseases is scarcely documented, particularly in low- and middle-income countries. This study aimed to document PC provided to patients with hematologic malignancies.

METHODS

Bidirectional study conducted from July 2016 to June 2019 at the hematology and palliative care departments at a reference center in Northeast Mexico for low-income open population uninsured patients. Clinical records and electronic files of patients with malignant hematological diseases of both sexes and all ages attending an academic hematology center were reviewed. Statistical analysis was performed with the SPSS version 22 program. Acute and chronic leukemias, multiple myeloma, Hodgkin lymphoma, non-Hodgkin lymphoma, and others were included.

RESULTS

Five-hundred ten patients were studied, of which 148 (29%) died. Eighty-one (15.88%) patients including 31 (20.9%) who died received PC. Median age at palliative diagnosis was 42 (2-91) years. The most common symptom was pain (69.7%). The most frequent reason for palliative referral was treatment-refractory disease (39%). During the last week of life, 19 (95%) of 20 patients had blood sampling; 17 (85%) received antibiotics; 16 (80%) had a urinalysis performed; 16 (80%) received analgesia, including paracetamol (11, 35.5%) and buprenorphine (7, 22.6%); 10 (50%) received blood products; 9 (45%) were intubated; and central venous catheters were inserted in 5 (25%) patients.

CONCLUSIONS

Palliative care was provided to a minority of patients with hematologic malignancies and considerable improvement is required in its timely use and extension.