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Weisse CS, Melekis K, Cheng A, Konda AK, Major A. Mixed-Methods Study of End-of-Life Experiences of Patients With Hematologic Malignancies in Social Hospice Residential Home Care Settings. JCO Oncol Pract 2024; 20:779-786. [PMID: 38306585 DOI: 10.1200/op.23.00534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/28/2023] [Accepted: 12/21/2023] [Indexed: 02/04/2024] Open
Abstract
PURPOSE Hospice is underutilized by patients with hematologic malignancies (HM), and when patients are referred, they are typically more ill, hospitalized, and with shorter length of stay (LOS) than patients with solid tumors (ST), limiting research about home hospice care experiences of patients with HM. In this mixed-methods study, we examined the hospice experiences of patients with HM who died at residential care homes (RCHs), home-based settings in which volunteer caregivers and hospice staff provide end-of-life (EOL) care under the social hospice model. METHODS We queried a registry of 535 hospice patients who died at RCHs between 2005 and 2020 that included quantitative medication administration data as well as qualitative data from hospice intake forms and written volunteer caregiver narratives. Qualitative data were analyzed by collective case study methodology. Quantitative comparisons of LOS and liquid morphine use were performed with matched patients with ST. RESULTS The registry yielded 29 patients with HM, of whom qualitative data were available for 18 patients. Patients with HM exhibited common EOL symptoms (pain, dyspnea, and agitation). Instances of bleeding were low (22%), and notable HM-specific care concerns were described regarding bone fractures, skin integrity, and delirium. Most (78%) experienced good symptom management and peaceful or comfortable deaths. In only one case were symptoms described as severe and poorly managed. Patients with HM had comparable LOS on hospice and at the RCHs to patients with ST, with no group differences in liquid morphine use. CONCLUSION In this registry cohort, most patients with HM achieved good symptom management in home care settings with volunteer caregivers and hospice support. Caregivers may require additional counseling and palliative medications for HM-specific EOL symptoms.
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Affiliation(s)
- Carol S Weisse
- Department of Psychology, Union College, Schenectady, NY
| | - Kelly Melekis
- College of Education and Social Services, University of Vermont, Burlington, VT
| | | | | | - Ajay Major
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, Divatia JV, Kumar A, Iyer SK, Deodhar J, Bhat RS, Salins N, Thota RS, Mathur R, Iyer RK, Gupta S, Kulkarni P, Murugan S, Nasa P, Myatra SN. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024; 28:200-250. [PMID: 38477011 PMCID: PMC10926026 DOI: 10.5005/jp-journals-10071-24661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs. How to cite this article Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.
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Affiliation(s)
- Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Kaushambi, Uttar Pradesh, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Butola
- Department of Palliative Care, Border Security Force Sector Hospital, Panisagar, Tripura, India
| | - Roop Gursahani
- Department of Neurology, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Dhvani Mehta
- Division of Health, Vidhi Centre for Legal Policy, New Delhi, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care, and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd, Mohali, Punjab, India
| | - Shiva K Iyer
- Department of Critical Care, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jayita Deodhar
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology and Palliative Medicine, SPARSH Hospitals, Bengaluru, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Raghu S Thota
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Roli Mathur
- Department of Bioethics, Indian Council of Medical Research, Bengaluru, Karnataka, India
| | - Rajam K Iyer
- Department of Palliative Care, Bhatia Hospital; P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Sangeetha Murugan
- Department of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Malakian A, Rodin G, Widger K, Ali R, Mahendiran AE, Mayo SJ. Experience of Care Among Adults With Acute Leukemia Near the End of Life: A Scoping Review. J Palliat Med 2024; 27:255-264. [PMID: 37738328 DOI: 10.1089/jpm.2023.0130] [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] [Indexed: 09/24/2023] Open
Abstract
Background: Acute leukemia is a cancer of the blood and bone marrow with a high symptom burden and a high mortality rate in adults. The quality of end-of-life care among this patient population is deemed to be low based on health care administrative data, though the patient experience is not included in this evaluation. Objective: This scoping review aims at exploring and mapping the current research literature on the experience of care among adults with incurable acute leukemia near the end of life. Design: The JBI framework guided our scoping review, and the protocol was prospectively registered in the Open Science Forum. Results: A total of 5661 unique articles were screened for title and abstract, and 44 were selected for full text. After a manual search, five studies published in seven articles were selected for data extraction, including three qualitative and two quantitative studies. Two studies used family caregivers as patient proxies, two studies engaged patients directly, whereas one study obtained data from patients and family caregivers. Patient care in acute settings was reported in all studies, with most patients dying in acute care settings. Patients and family caregivers often valued an open and honest approach, with sufficient time for dialogue with their providers. Discussions about prognosis, palliative care, and hospice care were often late or incomplete. The medicalization of end-of-life care, including intensive care unit admissions and invasive medical procedures, were viewed as the norm by some providers, though perceived as distressing for both patients and their loved ones. Conclusions: Adults with acute leukemia face significant challenges in accessing high-quality end-of-life care brought about by the complex nature of their disease and its treatment. A systematic exploration of the end-of-life experience among these patients through direct patient engagement or by way of patient reporting proxies is needed.
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Affiliation(s)
- Argin Malakian
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Gary Rodin
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care, University Health Network (UHN), Toronto, Ontario, Canada
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Lifespan Program, ICES, Toronto, Ontario, Canada
| | - Ridwaanah Ali
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Angela E Mahendiran
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Samantha J Mayo
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
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Rao V, Linsky S, Knobf MT. Perspectives of Patients With Relapsed and Refractory Acute Myeloid Leukemia and High-Risk Myelodysplastic Syndrome on Patient-Clinician Communication About Prognosis and the Future. Palliat Med Rep 2024; 5:53-62. [PMID: 38249836 PMCID: PMC10797310 DOI: 10.1089/pmr.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Background Patients with acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) experience unpredictable disease trajectories and high prognostic uncertainty, which serve as barriers to patient-clinician communication about prognosis and their values and preferences for the future in the event of worsening health. Little is known about patients' day-to-day lived experiences and how this shapes their willingness to engage in such conversations. Objectives To explore participant perspectives on living with their illness and patient-clinician communication about prognosis and the future. Design This is a qualitative study using semi-structured interviews. Setting/Subjects Patients with relapsed and refractory (R/R) AML and high-risk MDS from a northeastern U.S. cancer center. Data Collection Interviews were transcribed verbatim and thematic analysis was used to generate findings. Results Of the 14 participants, the mean age was 66 years, 79% were men, 93% were White, married, and had AML. The overarching theme that describes the experience was "Taking One Day at a Time" in a Fog of Uncertainty. Uncertainty was a universal perception related to the challenges for clinicians to predict prognosis. To cope with uncertainty, most participants tried to focus on the present and maintain normality in everyday life. Participants valued encouragement and positivity in patient-clinician communication, however, the majority were not ready to discuss prognosis and the future in the event of worsening health. Of note, 7 of 14 participants died within three months after the interview. Conclusions These data describe a unique perspective of patients with R/R AML and high-risk MDS that clinicians could use to enhance communication strategies.
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Affiliation(s)
- Vinay Rao
- Division of Palliative Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Linsky
- School of Nursing, Yale University, Orange, Connecticut, USA
| | - M. Tish Knobf
- School of Nursing, Yale University, Orange, Connecticut, USA
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Gebel C, Basten J, Kruschel I, Ernst T, Wedding U. Knowledge, feelings, and willingness to use palliative care in cancer patients with hematologic malignancies and solid tumors: a prospective, cross-sectional study in a comprehensive cancer center in Germany. Support Care Cancer 2023; 31:445. [PMID: 37410174 DOI: 10.1007/s00520-023-07914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Patients with hematologic malignancies (HM) receive palliative care (PC) less often and later than patients with solid tumors (ST). Patients' lack of knowledge about PC and negative feelings about PC are barriers to their willingness to use PC. Is there a difference between patients with HM and ST in their knowledge and willingness to use PC? METHODS Two hundred ten patients (85 HM, 125 ST) from an oncology day clinic at a university hospital participated in this cross-sectional, questionnaire-based survey. RESULTS Patients with HM and ST had high knowledge and mainly positive feelings about PC. More than half of the patients answered that they would feel reassured by the use of PC, and one-third would feel anxious or hopeless. The majority of patients (58.3%) were willing to use PC. There are no significant differences between patients with HM and ST. In multiple regression analysis, perceived chance of cure and feelings of reassurance and anxiety are associated with willingness to use PC, but not with the HM/ST disease group. More than half (53.9%) of the participants would like the treating physician to choose the timing of a discussion about PC. CONCLUSION Our study shows a high level of knowledge and relatively positive feelings of patients about PC, with no differences between patients with HM or ST. They expect their treating physician to initiate communication about PC. Communication should include the patient's feelings about PC and their chances of a cure.
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Affiliation(s)
- Cordula Gebel
- Department of Palliative Care, Jena University Hospital, Jena, Germany.
| | - Judith Basten
- Department of Palliative Care, Jena University Hospital, Jena, Germany
| | - Isabel Kruschel
- Department of Palliative Care, Jena University Hospital, Jena, Germany
| | - Thomas Ernst
- University Tumor Center, Jena University Hospital, Jena, Germany
| | - Ulrich Wedding
- Department of Palliative Care, Jena University Hospital, Jena, Germany
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Shu W, Miao Q, Feng J, Liang G, Zhang J, Zhang J. Exploring the needs and barriers for death education in China: Getting answers from heart transplant recipients' inner experience of death. Front Public Health 2023; 11:1082979. [PMID: 36860384 PMCID: PMC9968799 DOI: 10.3389/fpubh.2023.1082979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023] Open
Abstract
Background Promoting reflection about death may support better living, and how to carry out death education is an important issue to be addressed across the world. The purpose of the current study was to explore the attitude of heart transplant recipients toward death and their inner real experience to provide information for the development of death education strategies. Methods A phenomenological qualitative study was conducted using a snowball method. A total of 11 patients who had undergone heart transplantation more than 1-year ago were recruited for the current study for semi-structured interviews. Results A total of five themes were identified: "Not avoid talking about death," "Feeling fear about the pain in the process of death", "Wanting a good death at the end of life," "The richness of feelings during near-death is surprising," and "Being close to death makes people more receptive to death." Conclusion Heart transplant recipients have a positive attitude toward death and wish for "good death" at the end of life. These patients' near-death experiences and positive attitudes toward death during the course of their illness provided evidence of the need for death education in China and supported the experiential approach to death education.
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Affiliation(s)
- Wan Shu
- School of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - QunFang Miao
- School of Clinical Medicine, Hangzhou Normal University, Affiliated Hospital of Hangzhou Normal University, Hangzhou, China,*Correspondence: QunFang Miao ✉
| | - JieHui Feng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Medical College of Zhejiang University, Hangzhou, China
| | - GuanMian Liang
- Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Jing Zhang
- School of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Jinsheng Zhang
- School of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
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Kokaji M, Imoto N, Watanabe M, Suzuki Y, Fujiwara S, Ito R, Sakai T, Yamamoto S, Sugiura I, Kurahashi S. End-of-Life Care of Acute Myeloid Leukemia Compared with Aggressive lymphoma in Patients Who Are Eligible for Intensive Chemotherapy: An Observational Study in a Japanese Community Hospital. Palliat Med Rep 2023; 4:71-78. [PMID: 36960234 PMCID: PMC10029750 DOI: 10.1089/pmr.2022.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/25/2023] Open
Abstract
Background Patients with hematological malignancies (HMs) are reported to receive more aggressive care at the end of life (EOL) than patients with solid tumors. However, the reasons behind this occurrence are not fully understood. Objectives To examine whether the care at EOL for HMs is mainly because of the disease characteristics or hematologists' attitudes and systems of care, we compared the EOL care of patients with acute myeloid leukemia (AML) and diffuse large B cell lymphoma (DLBCL). Design We retrospectively analyzed the EOL care of patients with AML and DLBCL younger than 80 years who were receiving combination chemotherapy at a city hospital in Japan. Results Fifty-nine patients with AML and 65 with DLBCL were included. Those with AML received chemotherapy more often within their last 30 days (48% vs. 19%, p < 0.001) and 14 days (37% vs. 1.5%, p < 0.001) of life, and consulted the palliative team less frequently (5.3% vs. 29%, p < 0.001). In the last 3 years, the mortality rate in hematological wards decreased from 74% to 29% in the DLBCL group, but only from 95% to 90% in the AML group. In multivariate analysis, AML (odds ratio [OR] 0.065) and death before 2018 (OR, 0.077) were significant factors associated with reduced referrals to specialized palliative teams. Conclusion Patients with AML tend to have lesser access to specialized palliative care and fewer options for their place of death than those with DLBCL. Detailed EOL care plans are needed for these patients, considering the characteristics of the disease.
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Affiliation(s)
- Masato Kokaji
- Department of Postgraduate Clinical Training Center, Toyohashi Municipal Hospital, Toyohashi, Japan
- Department of Obstetrics and Gynecology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Naoto Imoto
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
- Address correspondence to: Naoto Imoto, MD, PhD, Department of Hematology and Oncology, Toyohashi Municipal Hospital, 50 Aza Hachiken Nishi, Aotake–Cho, Toyohashi, Aichi, Japan.
| | - Miki Watanabe
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Yutaro Suzuki
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Shinji Fujiwara
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
- Department of Hematology, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Rie Ito
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Toshiyasu Sakai
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Satomi Yamamoto
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Isamu Sugiura
- Department of Internal Medicine, Toyohashi Hematology Oncology Clinic, Toyohashi, Japan
| | - Shingo Kurahashi
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
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