Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development?

Management of Anemia in Renal Palliative Care Clinic: A Patient-Centered Approach

BACKGROUND

Despite the growing needs in nondialytic alternatives for conservative kidney management, few studies have examined the management of anemia in palliative care (PC) outpatient clinics, which represent the key point of entry for timely access to PC.

OBJECTIVE

A retrospective study to review for a patient-centered approach in anemia management and symptom control.

RESULTS

Over the study period from July 2020 to March 2023, a total of 158 patients were seen at our renal PC clinic, 47 were included in data analysis. Patients had a mean age and glomerular filtration rate of 81.3 (9.5) years and 8.6 (5.3) mL/min/1.73 m2, and 68.1% and 44.7% were receiving erythropoiesis-stimulating agents (ESAs) and iron supplements respectively, with only 4.3% of patients required transfusion over past six months. Mean hemoglobin was maintained at 9.8 (1.4) g/dL, with a mean POS-S renal score of 4.7 (3.2). Majority of patients (93.6%) had satisfactory rating on "weakness and lack of energy" item.

CONCLUSION

A patient-centered approach in anemia management at renal PC outpatient clinics may alleviate symptom burden and minimize transfusion requirement.

A multicentre survey on the perception of palliative care among health professionals working in haematology

PURPOSE

Patients with haematologic malignancies have less access to palliative care and are referred later than patients with solid tumours. We developed a survey to investigate this phenomenon, with the intention of analysing palliative care perceptions among health professionals who treat haematology patients and identifying barriers and facilitators to referrals to palliative care services.

METHODS

This was a multicentre exploratory descriptive web-based survey. A questionnaire was administered to 320 medical and nursing staff members from five Italian haematological units and San Marino's hospital to investigate their perception of palliative care. Quantitative and qualitative analyses were performed.

RESULTS

A total of 142/320 healthcare professionals completed the survey, achieving a 44% response rate. Most of the respondents supported the integration of haematology and palliative care and were aware of the role of palliative care. Despite this, only half had an in-hospital palliative care team, and only a few had previously attended a specific training course. The majority agreed with palliative care referral when the prognosis was less than 3 months or when the symptoms were incoercible and with blood transfusions even in the last stages of the disease. Many considered the presence of an in-hospital palliative care team or a case manager, as well as structured palliative care training, as fundamental facilitators of palliative care referrals.

CONCLUSION

These results showed that healthcare professionals in haematology generally hold a favourable attitude and a high interest in integrating palliative care into their patients' care. The low referral rate could depend on clinical, cultural, and organisational issues.

Variability in the perception of palliative care and end-of-life care among hematology professionals from the same reference center in Bahia, Brazil: A descriptive cross-sectional study

BACKGROUND

There are several illness-specific cultural and system-based barriers to palliative care (PC) integration and end-of-life (EOL) care in the field of oncohematology.

OBJECTIVES

This study aimed to investigate the variability in the perceptions of PC and EOL care.

DESIGN AND SETTING

A cross-sectional study was conducted in the Hematology Division of our University Hospital in Salvador, Bahia, Brazil.

METHODS

Twenty physicians responded to a sociodemographic questionnaire and an adaptation of clinical questionnaires used in previous studies from October to December 2022.

RESULTS

The median age of the participants was 44 years, 80% of the participants identified as female, and 75% were hematologists. Participants faced a hypothetical scenario involving the treatment of a 65-year-old female with a poor prognosis acute myeloid leukemia refractory to first-line treatment. Sixty percent of the participants chose to follow other chemotherapy regimens, whereas 40% opted for PC. Next, participants considered case salvage for the patient who developed septic shock following chemotherapy and were prompted to choose their most probable conduct, and the conduct they thought would be better for the patient. Even though participants were from the same center, we found a divergence from the most probable conduct among 40% of the participants, which was due to personal convictions, legal aspects, and other physicians' reactions.

CONCLUSIONS

We found considerable differences in the perception of PC and EOL care among professionals, despite following the same protocols. The study also demonstrated variations between healthcare professionals' beliefs and practices and persistent historical tendencies to prioritize aggressive interventions.

Clinical Features of Patients With Hematological Malignancies Treated at the Palliative Care Unit

Background

In Japan, the number of patients with aggressive hematological malignancies (PHMs) admitted at the palliative care unit (PCU) in their end-of-life (EOL) stage was fewer than that of patients with solid tumors due to several reasons. The assessment of patient characteristics and the methods of survival prediction among PHMs in the EOL stage are warranted.

Objectives

This study aimed to identify the current medical status and the method of survival prediction among PHMs treated at the PCU.

Setting/Subjects/Measurements

We retrospectively analyzed the clinical data of 25 PHMs treated at our PCU between January 2017 and December 2020. The association between survival time and the palliative prognostic score (PAP) and palliative prognostic index (PPI) was analyzed.

Results

The average age of the PHMs was higher than that of patients with lung cancer as a control. The median survival time of the PHMs was shorter than the control group. Most PHMs could not receive standard chemotherapy, and the most common cause of death was disease-related organ failure. Significant associations were observed between the survival time and each PAP/PPI value in patients with malignant lymphoma, but not in those with leukemia.

Conclusion

The PHMs in the PCU had a lower median survival time than the control group. These results were induced by the result of patient selection to avoid treatment-related severe toxicity. The survival prediction using the PAP and PPI was less accurate in patients with leukemia.

Palliative care needs of patients with hematologic malignancies and family caregivers and challenges of palliative care provision in Asia: A review of evidence

Patients with hematologic malignancies often experience fatigue, lack of vitality, and energy, and high psychological distress. High levels of unmet care needs of patients with hematologic malignancies in Asia were identified. This review provides an overview of current evidence on the experiences and palliative care needs of patients with hematologic malignancies and their families and the barriers and challenges of integrating palliative care into hematology care in Asia. Patients with hematologic malignancies who received palliative care could benefit from less aggressive end-of-life treatments. However, the uncertain and variable nature of the prognosis and illness trajectories of hematologic malignancies increase the difficulties of integrating palliative care into hematologic care. Patients and their families are often referred to palliative care services late, which leaves a short window for palliative care teams to provide holistic needs assessment and person-centered care for those who need it. In addition, cultural differences in medical decision-making patterns and complex social norms and interactions among patients, families, and healthcare staff make it even more challenging to initiate palliative care conversations in Asia. Future research should focus on the development and evaluation of culturally appropriate palliative care for patients with hematologic malignancies and their family caregivers in Asia, given that the low rate of service intake and poor public awareness of the important role of palliative care in disease trajectories were reported. The socio-cultural context surrounding individuals should be taken into consideration to ensure the provision of person-centered care for this group of patients. Digital health could be one of the possible solutions forward to address local needs and challenges.

Factors Associated With Survival in Patients With End-of-Life Hematological Malignancies Who Received Chemotherapy: A Retrospective Single-Institution Study

BACKGROUND

Clinicians can appropriately terminate treatment or reduce treatment intensity by determining prognostic factors of end-of-life chemotherapy. In particular, it provides important information for patients with hematological malignancies who receive chemotherapy until near-the-end of life compared with patients with solid tumors. This study aimed to clarify whether existing prognostic tools are associated with the survival in patients with end-of-life hematological malignancies who received chemotherapy.

METHODS

We retrospectively reviewed the records of 247 patients diagnosed with hematological malignancies and died at our university hospital hematology ward between May 2015 and May 2021. We performed multivariate analysis in 82 (33.2%) patients who received end-of-life chemotherapy using the Palliative Prognostic Index (PPI) and inflammation-based prognostic models, such as the Glasgow Prognostic Score (GPS), Prognostic Nutritional Index (PNI), and Controlling Nutrition Status (CONUT).

RESULTS

On comparing 82 patients who received end-of-life chemotherapy with 165 patients who did not, the proportion of patients with PPI group A, GPS score = 0, and CONUT normal/mild was significantly higher among patients who received chemotherapy. In multivariate analysis, we identified PPI groups B (2.0 < PPI ≤ 4.0) and C (PPI > 4.0) [hazard ratio (HR) 2.1290, 95% CI 1.1830-3.828, P = .01166, respectively] and age ≥ 65 years (HR 2.0170, 95% CI 1.1280-3.607, P = .01805) were associated with overall survival.

CONCLUSION

PPI use and age were independent associating factors for patients with hematological malignancies receiving end-of-life chemotherapy. PPI, a popular prognostic tool may be helpful for patients and hematologists to make decisions about end-of-life care.

Improving Outcome-Driven Care in Multiple Myeloma Using Patient-Reported Outcomes: A Qualitative Evaluation Study

BACKGROUND AND OBJECTIVE

Multiple myeloma is an incurable disease with a considerable illness and treatment burden, which negatively impacts patients' quality of life. This study aimed to evaluate the implementation of multiple myeloma care in five Dutch hospitals, related to the three objectives of outcome-driven care, which are defined as (1) providing information for shared decision making in individual patient care, (2) supporting the learning capacity of healthcare professionals and healthcare institutions through benchmarking and (3) developing outcome-driven and patient-centred contracting by health insurers.

METHODS

In this qualitative study, semi-structured interviews about experiences with patient-reported outcomes were conducted with patients, healthcare professionals and other stakeholders 2 years after implementation. Data were thematically analysed, and emerging topics were clustered around the three objectives of outcome-driven care.

RESULTS

A total of 46 interviews were held (15 with patients, 16 with professionals and 15 with other stakeholders) that showed patients with multiple myeloma were willing to complete patient-reported outcomes, although integration of patient-reported outcomes in shared decision making fell short in clinical practice. Aggregated patient-reported outcomes were considered important for improving quality of care; however, data collection and data exchange are hindered by privacy legislation, limitations of IT systems and a lack of data standards. Patient-reported outcomes were expected to contribute to cost-effective multiple myeloma treatment, yet outcome-driven reimbursement is still lacking.

CONCLUSIONS

Outcome-driven multiple myeloma care using patient-reported outcomes is feasible, provided that (1) patient-reported outcomes and shared decision making are integrated into clinical practice, (2) legal and technical obstacles hindering data collection are removed and (3) health insurers adjust their reimbursement plans to facilitate outcome-driven care.

Coping Skills Interventions for Fatigue in Adults with Hematologic Malignancies: A Systematic Review

Background: Persons with hematologic malignancies have a high symptom burden throughout the illness journey. Coping skills interventions effectively reduce fatigue for other cancer patients. The purpose of this systematic review is to identify if coping interventions can reduce fatigue in patients with hematologic malignancies. Methods: A search of PubMed, Embase, CINAHL, APA Psych INFO, Scopus, Cochrane, and non-traditional publications was performed in June 2021 for studies introducing coping interventions for adults with hematological cancers within the past 20 years. The Transactional Model of Stress and Coping was used as a framework with fatigue as the primary outcome. The Johns Hopkins Nursing Evidence Based Practice Appraisal tool was used for quality appraisal. Results: Twelve interventional studies met criteria for inclusion. Four studies significantly reduced fatigue, with an additional 3 showing a reduction in fatigue. Interventions that utilized both problem and emotion-focused coping were more effective at reducing fatigue compared to interventions that only used emotion or problem-focused coping. Conclusion: This systematic review found moderate-strength evidence to support that coping interventions can reduce fatigue, with mixed, but mostly beneficial results. Clinicians caring for patients with hematologic malignancies should consider using coping interventions to reduce fatigue.

Application of Medical-Nursing Integration Multidisciplinary-Assisted Surgical Wound Nursing Mode in Improving the Quality of Wound Treatment

Surgical treatment is a common clinical intervention for trauma, but postoperative pain and poor nursing lead to slow wound recovery and wound infection. Therefore, it is extremely important to select effective nursing intervention methods to improve the quality of wound treatment. This study explored the application value of the wound care model of medical integration and multidisciplinary-assisted surgery in improving the quality of wound treatment. The results show that medical-nursing integration in multidisciplinary-assisted surgical wound nursing mode can improve the quality of wound treatment and pain level in patients, which is beneficial to improving team cohesion of medical staff and satisfaction evaluation of patients.

Acute Myeloid Leukemia: Challenges in Delivering End-of-Life Care

Patients with Acute Myeloid Leukemia (AML) have a complex disease trajectory characterized by high symptom and psychosocial burden, a high rate of hospitalization and intensive care unit admission at the end-of-life (EOL), and frequent use of chemotherapy near the EOL. In addition, palliative and hospice care are underutilized in patients with AML despite their poor prognosis. Clinicians providing care to patients with end-stage AML frequently encounter multiple challenges, particularly surrounding the frequent administration of blood products near the EOL. We present a case of a patient with end-stage AML whose desire for transfusions causes significant patient and caregiver distress at the EOL. Balancing patient autonomy with the potentially inappropriate use of blood transfusions at the EOL and having good communication and collaboration among healthcare teams are important considerations when delivering optimal EOL care to patients with AML.

The effect of age on specialized palliative care use in the last year of life for patients who die of cancer: A nationwide study from Norway

INTRODUCTION

Specialized palliative care (SPC) is beneficial towards end of life because of its holistic approach to improve quality of life and comfort of patients and their families. Few studies have described how patient age, sex, comorbidities, and socioeconomic status (SES) are associated with SPC use in nonselective populations who die of cancer. This study aimed to evaluate the use of SPC in the year preceding death by all Norwegian individuals with a recent cancer diagnosis who died of cancer.

MATERIALS AND METHODS

From nationwide registries, we identified patients with a recent (<5 years) cancer diagnosis who died during 2010-2014. Using binary logistic regression models, we estimated the probability of receiving hospital-based SPC during the last year of life according to individual (age, sex, comorbidity), cancer (stage, type, and months since diagnosis), and SES (e.g., living alone, household income, and education) characteristics.

RESULTS

The analytical sample contained 45,521 patients with a median age at death of 75 years; 46% were women. The probability of receiving hospital-based SPC in the total cohort was 0.43 (95% confidence interval [CI] 0.42-0.43). Use of SPC was higher if patients were younger, female, had limited comorbidity, metastatic disease, had one the following cancer types: colorectal, pancreatic, bladder, kidney, or gastric, were diagnosed more than six months before death, and had higher SES. Adjusted model results suggested that the probability of using SPC in the last year of life for patients aged 80-89 years was 0.31 (95% CI 0.30-0.32), compared to a probability of 0.63 (95% CI 0.61-0.65) for patients aged 50-59 years. For patients ≥90 years, the probability was 0.16 (95% CI 0.15-0.18).

DISCUSSION

Less hospital-based SPC use among older patients, males, and those with lower SES indicates possible under-treatment in these groups. Future studies should be designed to determine the underlying reasons for these observed differences.

Utility of Palliative Prognostic Index in Predicting Survival Outcomes in Patients With Hematological Malignancies in the Acute Ward Setting

BACKGROUND

The palliative prognostic index (PPI) predicts the life expectancy of patients with terminally ill cancer in hospice settings. This study aimed to evaluate PPI as a prognostic tool for predicting the life expectancy of patients with hematological malignancies admitted to the acute ward.

METHODS

A total of 308 patients with hematological malignancies admitted to the hematological ward at a medical center between January 2016 and December 2017 were consecutively enrolled. PPI was scored within 24 h of admission. All patients were categorized into 3 groups by PPI for comparing survival and in-hospital mortality rates.

RESULTS

The median survival times were 38.4, 3.6, and 1.1 months for patients with good, intermediate, and poor prognostic group, respectively. The hazard ratio was 2.31 (95% CI 1.59-3.35, p < 0.001) when comparing the intermediate and good prognosis groups, and 3.90 (95% CI 2.52-6.03, p < 0.001) when comparing the poor and good prognosis groups. Forty-five (14.6%) patients died at discharge; in-hospital mortality rates among the good, intermediate, and poor prognostic groups were 9.0%, 23.4%, and 46.4%, respectively. The adjusted odds ratio for in-hospital mortality was 1.96 (95% CI, 0.80-4.82, p = 0.14) and 5.25 (95% CI, 2.01-13.7, p < 0.001) for patients in the intermediate and poor prognostic groups compared to those in the good prognostic group.

CONCLUSION

PPI is an accurate prognostic tool for predicting survival times and in-hospital mortality rates in patients with hematological malignancies in an acute ward setting. PPI could assist clinicians in discussing end-of-life issues and in referring patients with hematological malignancies to palliative care.

Lean Into the Uncomfortable: Using Trauma-Informed Care to Engage in Shared Decision-Making With Racial Minorities With Hematologic Malignancies

Discussions involving racial health disparities must include pathways for engaging in shared decision-making with racial/ethnic minorities. Research demonstrates glaring racial and ethnic disparities when it comes to hematologic malignancies from the time of diagnosis to treatment and even at the end of life. Unfortunately, decision-making in these circumstances may be streamlined, given the urgency of the disease, prognostic uncertainty, and varying treatment options. Being diagnosed with cancer is undoubtedly a traumatic experience and a patient's race and/or ethnicity add an important dimension to their experience. The tenets of trauma-informed care (TIC) are anchored in recognizing that trauma can manifest in several ways and acknowledging the impact of past trauma on a patient's present and future behaviors. We argue that using a TIC approach may help hematologists create a space for decision-making while minimizing the risk of re-traumatization and perpetuating racial disparities. Using the foundation of TIC, an interprofessional team can begin addressing manifestations of trauma and hopefully mitigate racial and ethnic disparities.