Catastrophic bleeds during end-of-life care in haematology: controversies from Australian research

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

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.

A qualitative evidence synthesis of healthcare professionals' experiences and views of palliative care for patients with a haematological malignancy

INTRODUCTION

Patients with haematological malignancies may not be receiving appropriate referrals to palliative care and continuing to have treatments in the end stages of their disease. This systematic review of qualitative research aimed to synthesise healthcare professionals' (HCPs) views and experiences of palliative care for adult patients with a haematologic malignancy.

METHODS

A systematic search strategy was undertaken across eight databases. Thomas and Harden's approach to thematic analysis guided synthesis on the seventeen included studies. GRADE-GRADEQual guided assessment of confidence in the synthesised findings.

RESULTS

Three analytic themes were identified: (a) "Maybe we can pull another 'rabbit out of the hat'," represents doctors' therapeutic optimism, (b) "To tell or not to tell?" explores doctors' decision-making around introducing palliative care, and (c) "Hospice, home or hospital?" describes HCPs concerns about challenges faced by haematology patients at end of life in terms of transfusion support and risk of catastrophic bleeds.

CONCLUSION

Haematologists value the importance of integrated palliative care but prefer the term "supportive care." Early integration of supportive care alongside active curative treatment should be the model of choice in haematology settings in order to achieve the best outcomes and improved quality of life.

Platelet transfusions in haematologic malignancies in the last six months of life

BACKGROUND AND OBJECTIVES

Practices in end-of-life platelet transfusions in haematologic malignancies are variable. Our aim was to describe the platelet transfusion burden and parameters linked to this indication in such a setting and thereby contribute to defining optimal practices.

MATERIALS AND METHODS

From July 2015 to December 2016, all consecutive deceased adult patients with a haematologic malignancy receiving a platelet transfusion in the last 6 months of their life from the Etablissement Français du Sang Bourgogne Franche-Comté were included retrospectively. The outcome criteria were changes in the number of platelet transfusions, percent platelet recovery, platelet transfusion interval, reported bleeding with its grade and recipient adverse events in the last 6 months of life.

RESULTS

Among the 1125 patients monitored, 119 were included in our study. Bleeding prophylaxis (versus treatment) was the reason for 55% of transfusions. 18% of platelet concentrates (n = 1999) were transfused during the last two weeks of life. As death approached, the transfusion and haemorrhage burden increased (P < 0·0001 in both cases), whereas platelet recovery and transfusion interval decreased (P = 0·02 in both cases). Recipient adverse events were rare (0·6%) and of minor severity.

CONCLUSION

In end-of-life transfused patients with haematologic malignancies, approaching death is associated with an increased number of platelet transfusions and bleeding events, while platelet recovery and transfusion intervals are reduced. Such findings, together with further evaluations, may contribute to informing best practices for these patients.

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review

BACKGROUND

Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed.

METHODS

Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients.

RESULTS

Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary.

CONCLUSION

Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

Being on the Frontline: Nurses' Experiences Providing End-of-Life Care to Adults With Hematologic Malignancies

The aim of this study was to explore the experiences of nurses providing end-of-life care to patients with hematologic malignancies, in a hematology oncology setting, in an acute general hospital. A qualitative hermeneutic phenomenological design was used, and 2 sets of semistructured interviews were conducted with 5 female nurses. The transcribed texts were analyzed using Interpretative Phenomenological Analysis. Two main themes emerged: "battling against medical futility" and "struggling with the emotional burden of care." Nurses perceived that the transfer of these patients at end of life to intensive critical care settings, coupled with the particularly aggressive treatments and corresponding symptom burden, prevented them from experiencing a dignified death. Consequently, nurses struggled with a gamut of emotions that included feelings of helplessness, distress, and compassion fatigue. Providing nursing care at end of life was perceived to be particularly challenging with the younger patients or with those who reminded them of family members. The findings highlight the unique challenges experienced by these nurses and the need to support them in their work with patients having hematologic malignancies at end of life within a well-resourced setting.

Ethics of crisis sedation: questions of performance and consent

This paper focuses on the practice of injecting patients who are dying with a relatively high dose of sedatives in response to a catastrophic event that will shortly precipitate death, something that we term 'crisis sedation.' We first present a confabulated case that illustrates the kind of events we have in mind, before offering a more detailed account of the practice. We then comment on some of the ethical issues that crisis sedation might raise. We identify the primary value of crisis sedation as allowing healthcare professionals to provide some degree of reassurance to patients, their families and the professionals who are caring for them. Next we focus on the issue of informed consent. Finally, we ask whether continuous deep sedation might be preferable to crisis sedation in scenarios where potential catastrophic events can be anticipated.

Pre-emptive prescription of medications for the management of potential, catastrophic events in patients with a terminal illness: A survey of palliative medicine doctors

Background:

Distressing and potentially life-threatening events, such as significant external bleeding, may occur in patients with a known terminal condition. These events are often referred to as catastrophic or crisis events. Pharmacological management varies and there is little evidence to guide practice.

Aim:

The aim of this study was to explore Australasian palliative medicine doctors’ approaches to pre-emptive prescription of medications to manage catastrophic events.

Design:

Anonymous survey data were collected electronically.

Setting/Participants:

Australian and New Zealand palliative medicine fellows and trainees were surveyed.

Results:

Surveys were completed by 121 doctors; 108 (89.2%) who care for adult patients only and 13 (10.8%) who care for paediatric patients or paediatric and adult patients. In all, 74 (61.2%) respondents pre-emptively prescribed medications at least five times per year, and most orders were never administered. Significant visible bleeding and severe, acute airway obstruction were almost universally considered catastrophic events. Many respondents expressed concern about the lack of evidence to guide pre-emptive medication prescription in this setting. Clinicians reported adverse events related to pre-emptive medication orders being available ( n = 30, 24.8%), as well as orders not being available ( n = 61, 50.4%).

Conclusion:

Our study supports the need for guidelines, as well as formal education programmes for medical trainees and nursing staff about this important area of practice.

Enquiry into Practice: Management of Terminal Catastrophic Intracranial Haemorrhage in Palliative Care

The management of terminal catastrophic haemorrhage is a rare clinical palliative emergency for which the management is based largely on anecdotal and experiential guidelines, with no high grade evidence but rather robust contention and controversy. Whilst often rapid and deadly, inevitably dramatic and devastating for the treating health professionals and family, the key management areas include risk identification, supportive practices, the use of sedative medication and the ethical issues faced in the management of terminal haemorrhage.

Palliative care in patients with haematological neoplasms: An integrative systematic review

BACKGROUND

Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies.

AIM

To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments.

DESIGN

Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240).

DATA SOURCES

PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies.

RESULTS

The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking.

CONCLUSION

Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.

Characteristics and outcomes of patients admitted to the acute palliative care unit from the emergency center

CONTEXT

Most patients admitted to acute palliative care units (APCUs) are transferred from inpatient oncology units. We hypothesized that patients admitted to APCUs from emergency centers (ECs) have symptom burdens and outcomes that differ from those of transferred inpatients.

OBJECTIVES

The purpose of this retrospective cohort study was to compare the symptom burdens and survival rate of patients admitted to an APCU from an EC with those of inpatients transferred to the APCU.

METHODS

Among the 2568 patients admitted to our APCU between September 1, 2003 and August 31, 2008, 312 (12%) were EC patients. We randomly selected 300 inpatients transferred to the APCU as controls (The outcome data were unavailable for two patients). We retrieved data on patient demographics, cancer diagnosis, Edmonton Symptom Assessment System scores, discharge outcomes, and overall survival from time of admission to the APCU.

RESULTS

The EC patients had higher rates of pain, fatigue, nausea, and insomnia and were less likely to be delirious. They were more than twice as likely to be discharged alive than transferred inpatients. Kaplan-Meier plot tests for product-limit survival estimate from admission to APCU for EC patients and inpatients were statistically significant (median survival 34 vs. 31 days, P<0.0001). In multivariate analysis, EC admission (odds ratio [OR]=1.8593, 95% confidence interval [CI] 1.1532-2.9961), dyspnea (OR=0.8533, 95% CI 0.7892-0.9211), well-being (OR=1.1192, 95% CI 1.0234-1.2257), and delirium (OR=0.3942, 95% CI 0.2443-0.6351) were independently associated with being discharged alive.

CONCLUSION

The EC patients have a higher acute symptom burden and are more likely to be discharged alive than transferred inpatients. The APCU was successful at managing symptoms and facilitating the discharge of both inpatients and EC patients to the community although the patients had severe symptoms on admission.

Nurses' experiences with catastrophic upper gastrointestinal bleeding in patients with hepatocellular carcinoma: a qualitative study

PURPOSE

To explore how nurses experienced catastrophic upper gastrointestinal bleeding in hepatocellular carcinoma (HCC) patients.

METHODS

A qualitative descriptive method was used. Data were collected by semi- structured interviews. Twenty-one registered nurses who had taken care of HCC patients with catastrophic upper gastrointestinal bleeding were purposely recruited from the Department of Hepatobiliary Cancer, Tianjin Medical University Cancer Institute and Hospital located in mainland China.

RESULTS

Four themes explicated from the study were: feelings expressed during the process of rescuing the lives of patients, feelings expressed from succeeding or failing to save the lives of patients, feelings expressed from family members response to nurses' actions, the impact of the experience on the personal life, work and philosophy of life of the nurse subjects.

CONCLUSIONS

The findings of this study indicate that it is necessary for nursing leaders to take effective measures to improve nurses' nursing skills, to provide more education in care of the dying, to offer nurses services that address their psychosocial health and to provide them with emotional support.