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Duffy E, O'Mahony F, Burke C, Conneely A, O'Connell H, Twomey F. Red cell transfusion benefits in oncology, haematology and palliative medicine populations: a narrative review. BMJ Support Palliat Care 2023; 13:291-297. [PMID: 34475134 DOI: 10.1136/bmjspcare-2021-003052] [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: 03/17/2021] [Accepted: 06/04/2021] [Indexed: 11/04/2022]
Abstract
Due to the heterogenous nature of the palliative medicine patient population, assessment of benefit, and thus choice of appropriate patient for consideration of transfusion, can be challenging. This can be confounded by the use of both liberal and restrictive transfusion thresholds. The multifactorial nature of many symptoms of anaemia, particularly in patients with advanced malignancy, can further complicate. As such, there is a paucity of data supporting the subjective, objective and clinical benefit of red cell transfusion in the palliative medicine setting. This narrative review summarises the research and evidence surrounding the benefits of red cell transfusion, with a particular emphasis on the oncological, haematological and palliative medicine population. There is a lack of a validated, reproducible patient-reported outcome measures (PROM) to assess response to red cell transfusions in the palliative medicine population with outcome measures varying from objective improvement in haemoglobin level post-transfusion, to subjective response in primary symptom(s). Further investigation is required regarding the development of effective PROMs assessing response to red cell transfusion in the palliative medicine population, to ensure judicious use of this scarce and valuable resource.
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Affiliation(s)
- Ed Duffy
- Palliative Medicine, Milford Care Centre, Castletroy, Limerick, Ireland
| | - Frances O'Mahony
- Palliative Medicine, Our Lady's Hospice & Care Services, Dublin, Ireland
| | - Caroline Burke
- Palliative Medicine, Milford Care Centre, Castletroy, Limerick, Ireland
| | - Aoibheann Conneely
- Palliative Medicine, Our Lady's Hospice & Care Services, Dublin, Ireland
| | - Helen O'Connell
- Palliative Medicine, Milford Care Centre, Castletroy, Limerick, Ireland
| | - Feargal Twomey
- Palliative Medicine, Milford Care Centre, Castletroy, Limerick, Ireland
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Santivasi WL, Childs DS, Wu KL, Partain DK, Litzow MR, LeBlanc TW, Strand JJ. Perceptions of Hematology Among Palliative Care Physicians: Results of a Nationwide Survey. J Pain Symptom Manage 2021; 62:949-959. [PMID: 33933620 DOI: 10.1016/j.jpainsymman.2021.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States.
| | - Daniel S Childs
- Departments of Medicine and Oncology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kelly L Wu
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, United States
| | - Daniel K Partain
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Jacob J Strand
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
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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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Chin-Yee N, Scott M, Perelman I, Pugliese M, Tuna M, Fitzgibbon E, Downar J, Tinmouth A, Fergusson D, Tanuseputro P, Saidenberg E. Red blood cell transfusion and associated outcomes in patients referred for palliative care: A retrospective cohort study. Transfusion 2021; 61:2317-2326. [PMID: 34145904 DOI: 10.1111/trf.16560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND We aim to describe the occurrence of red blood cell transfusion and associated predictive factors and outcomes among patients referred for palliative care. STUDY DESIGN AND METHODS This retrospective cohort study used linked health administrative data of adults referred for palliative care at an academic hospital from 2014 to 2018. Multivariable regression models were employed to evaluate patient characteristics associated with transfusion and the relationship between transfusion status and location of death. Survival analyses were performed using log-rank tests and Cox proportional hazards modeling. RESULTS Of 6980 evaluated patients, 885 (12.7%) were transfused following palliative care consultation. Covariate factors associated with transfusion included younger age, higher performance status, lower baseline hemoglobin, and a diagnosis of hematologic malignancy (OR = 2.97, 95% CI 2.20-4.01) or solid organ tumor (OR = 1.37, 95% CI 1.10-1.71) vs. noncancer diagnosis. Median survival from palliative care consultation was 19 (IQR 5-75) days; 83 (32-305) days in those transfused and 15 (4-57) days in the nontransfused group (p < .0001). Median survival following transfusion was 56 (19-200) days. Solid organ tumor diagnosis was independently associated with poor survival (HR = 1.7, 95% CI 1.39-2.09 vs. non-cancer diagnosis). Among individuals who survived ≥30 days, transfusion was associated with a higher likelihood of death in hospital (OR = 2.15, 95% CI 1.71-2.70 vs. home/subacute setting). DISCUSSION Transfusions commonly occurred in patients receiving palliative care, associated with cancer diagnoses and favorable baseline prognostic factors. Poor survival following transfusion, particularly in solid organ tumor patients, and the twofold likelihood of death in hospital associated with this intervention have important implications in prescribing transfusion for this population.
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Affiliation(s)
- Nicolas Chin-Yee
- St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Mary Scott
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Iris Perelman
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Pugliese
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Meltem Tuna
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | | | - James Downar
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
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Chin-Yee N, Taylor J, Downar J, Tanuseputro P, Saidenberg E. Red Blood Cell Transfusion in Palliative Care: A Survey of Palliative Care Physicians. J Palliat Med 2019; 22:1139-1142. [DOI: 10.1089/jpm.2018.0605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nicolas Chin-Yee
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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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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Lin RJ, Elko TA, Perales MA, Alexander K, Jakubowski AA, Devlin SM, Dahi PB, Papadopoulos EB, Klimek VM, Giralt SA, Nelson JE. End-of-life care for older AML patients relapsing after allogeneic stem cell transplant at a dedicated cancer center. Bone Marrow Transplant 2019; 54:700-706. [PMID: 30135464 PMCID: PMC6751554 DOI: 10.1038/s41409-018-0311-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 11/08/2022]
Abstract
Older patients with acute myelogenous leukemia (AML) are at increased risk for mortality and morbidity. While allogeneic stem cell transplantation may provide cure in some patients, many still relapse after transplant and are then left with limited therapeutic options and poor survival. Moreover, the quality of the end-of-life care for these patients has not been previously reported. We describe here the end-of-life experience of a cohort of 72 older patients with AML who relapsed after first allogeneic stem cell transplant at our dedicated cancer center. Despite a median overall survival of only 4 months, we find a high level of primary palliative care delivered by transplant/leukemia physicians through goals of care discussions and/or advanced care planning and provide evidence for high-quality end-of-life care outcomes, often with concurrent disease-directed therapy. Our results compare favorably with end-of-life care outcomes reported for older AML patients, including those who did not undergo transplant. Given the poor prognosis and unique underlying vulnerabilities in this high-risk patient population, incorporating timely advanced care planning and palliative care delivery while exploring available salvage options may further improve end-of-life care outcomes.
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Affiliation(s)
- Richard J Lin
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Theresa A Elko
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Miguel-Angel Perales
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Koshy Alexander
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann A Jakubowski
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Sean M Devlin
- Epidemiology-Biostatistics, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Parastoo B Dahi
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Esperanza B Papadopoulos
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Virginia M Klimek
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Judith E Nelson
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Supportive Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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