1
|
Patel RV, Ali F, Chiad Z, Chojecki AL, Webb JA, Rosa WE, LeBlanc TW. Top Ten Tips Palliative Care Clinicians Should Know About Acute Myeloid Leukemia. J Palliat Med 2024; 27:794-801. [PMID: 38064538 DOI: 10.1089/jpm.2023.0638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults. Rapidly proliferating leukemic cells cause symptoms and increase the risk of infection. While individuals may initially benefit from supportive measures, disease-directed therapy may ultimately be required for symptom management, even at the end of life, although this may also inadvertently increase symptom burden. This unpredictable illness trajectory complicates prognostic uncertainty and the timing of hospice referral, which may prohibit access to palliative therapies and lead to recurrent hospitalizations. However, emerging evidence demonstrates that early palliative care (PC) integration with standard leukemia care results in improved quality of life, psychological outcomes, and greater participation in advance care planning. To orient PC clinicians asked to care for patients with AML, this article highlights 10 salient considerations.
Collapse
Affiliation(s)
- Rushil V Patel
- Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fatima Ali
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Zane Chiad
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | | | - Jason A Webb
- Section of Palliative Care, Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas W LeBlanc
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| |
Collapse
|
2
|
Hsieh TC, Yeo YH, Zou G, Zhou C, Ash A. Disparities in Palliative Care Use for Patients With Blood Cancer Who Died in the Hospital. Am J Hosp Palliat Care 2024:10499091241254523. [PMID: 38803232 DOI: 10.1177/10499091241254523] [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: 05/29/2024] Open
Abstract
Background: Palliative care can enhance quality of life during a terminal hospitalization. Despite advances in diagnostic and treatment tools, blood cancers lag behind solid malignancies in palliative use. It is not clear what factors affect palliative care use in blood cancer. Methods: We used the 2016 to 2019 National Inpatient Sample to identify demographic and socioeconomic factors associated with receiving palliative care among patients over age 18 with any malignant hematological diagnosis during a terminal hospitalization lasting at least 3 days, excluding those receiving a stem cell transplant. Results: Palliative care use was documented 54% of the time among 49,720 weighted cases (9944 distinct individual hospitalizations), approximately evenly distributed across the years 2016-2019. Palliative care use was lowest in 2016 (51%) and highest in 2018 (58%), and increased with age, reaching 58% for those 80 years and older. Men and women were similarly likely to receive care. Patients of Hispanic ethnicity and African Americans received less palliative care (47% and 49%, respectively), as did those insured by Medicaid (48%), and those admitted to small or rural hospitals (52% and 47%, respectively). Charges for hospitalizations with palliative care were 19% lower than for those without it. Conclusions: This study highlights disparities in palliative care use among blood-cancer patients who died in the hospital. It seems likely that many of the 46% who did not receive palliative care could have benefitted from it. Interventions are likely needed to achieve equitable access to ideal levels of palliative care services in late-stage blood cancer.
Collapse
Affiliation(s)
- Tien-Chan Hsieh
- Division of Hematology-Oncology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Yee Hui Yeo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Guangchen Zou
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chan Zhou
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Program in Bioinformatics and Integrative Biology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- The RNA Therapeutics Institute, University of Massachusetts Chan Medical School, Worcester, MA, USA
- UMass Cancer Center, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Arlene Ash
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
McInturf G, Younger K, Sanchez C, Walde C, Abdallah AO, Ahmed N, Shune L, Sborov DW, Godara A, McClune B, Sinclair CT, Mohyuddin GR. Palliative care utilization, transfusion burden, and end-of-life care for patients with multiple myeloma. Eur J Haematol 2022; 109:559-565. [PMID: 36054450 DOI: 10.1111/ejh.13843] [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: 05/20/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Despite treatment advances, multiple myeloma (MM) remains a significant source of morbidity and mortality. We aimed to examine specialist palliative care (SPC) involvement and end-of-life care for patients with MM. METHODS We assessed all deceased patients with a diagnosis of MM who received care at a single institution from January 2010 to December 2019 and assessed SPC involvement. RESULTS We reviewed 456 deceased patients. Overall, 207 patients (45.4%) received SPC visits by clinicians during their disease, and 153 (33.5%) were on MM treatment in the month before death. Median time from SPC consultation to death was 1 month, with 42 (9.2%) of patients receiving SPC visits 6 or more months before death. Amongst the patients for which a place of death was reported (351), 117 (33.3%) died in the acute care setting. Outpatient SPC did not correlate with a reduction of death in the acute care setting. In the group of patients who received outpatient SPC, 22/84 (26.2%) died in an acute care setting, whereas 95/267 (35.5%) patients who did not receive outpatient SPC also died in an acute care setting, (p = .11). CONCLUSION In our analysis of the entire trajectory of the MM patient experience from diagnosis to death, we found low rates of SPC involvement and a significant proportion of patients receiving aggressive care at end-of-life. While there is no clear correlation that SPC involvement impacted the rate of acute care deaths or decreased utilization of MM treatment in the last month of life, further prospective research on optimal utilization of SPC is required.
Collapse
Affiliation(s)
- Geoffrey McInturf
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Kimberly Younger
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Courtney Sanchez
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Charles Walde
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Al-Ola Abdallah
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Nausheen Ahmed
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Leyla Shune
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Douglas W Sborov
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| | - Amandeep Godara
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| | - Brian McClune
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Ghulam Rehman Mohyuddin
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
5
|
Poor E, Chan YN, Iadonisi K, Tan K, Leak Bryant A. Exploring Experiences of Bereaved Caregivers of Older Adult Patients With Acute Myeloid Leukemia. Clin J Oncol Nurs 2022; 26:135-139. [PMID: 35302558 DOI: 10.1188/22.cjon.135-139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Caregivers of older adults with acute myeloid leukemia (AML) are requiring more support now that novel, nonintensive therapies, such as hypomethylating agents and venetoclax, are shifting the burden of care to the outpatient setting. Early findings from a larger study describe supportive care needs from the perspective of bereaved caregivers that align with existing research, informing the development of best practices for oncology nurses who support caregivers of older adults with AML.
Collapse
Affiliation(s)
| | | | | | - Kelly Tan
- University of North Carolina at Chapel Hill
| | | |
Collapse
|
6
|
Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:cancers13205075. [PMID: 34680226 PMCID: PMC8534216 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
Collapse
|
7
|
Sheridan R, Roman E, Smith AG, Turner A, Garry AC, Patmore R, Howard MR, Howell DA. Preferred and actual place of death in haematological malignancies: a report from the UK haematological malignancy research network. BMJ Support Palliat Care 2021; 11:7-16. [PMID: 32393531 PMCID: PMC7907576 DOI: 10.1136/bmjspcare-2019-002097] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/18/2020] [Accepted: 04/04/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Hospital death is comparatively common in people with haematological cancers, but little is known about patient preferences. This study investigated actual and preferred place of death, concurrence between these and characteristics of preferred place discussions. METHODS Set within a population-based haematological malignancy patient cohort, adults (≥18 years) diagnosed 2004-2012 who died 2011-2012 were included (n=963). Data were obtained via routine linkages (date, place and cause of death) and abstraction of hospital records (diagnosis, demographics, preferred place discussions). Logistic regression investigated associations between patient and clinical factors and place of death, and factors associated with the likelihood of having a preferred place discussion. RESULTS Of 892 patients (92.6%) alive 2 weeks after diagnosis, 58.0% subsequently died in hospital (home, 20.0%; care home, 11.9%; hospice, 10.2%). A preferred place discussion was documented for 453 patients (50.8%). Discussions were more likely in women (p=0.003), those referred to specialist palliative care (p<0.001), and where cause of death was haematological cancer (p<0.001); and less likely in those living in deprived areas (p=0.005). Patients with a discussion were significantly (p<0.05) less likely to die in hospital. Last recorded preferences were: home (40.6%), hospice (18.1%), hospital (17.7%) and care home (14.1%); two-thirds died in their final preferred place. Multiple discussions occurred for 58.3% of the 453, with preferences varying by proximity to death and participants in the discussion. CONCLUSION Challenges remain in ensuring that patients are supported to have meaningful end-of-life discussions, with healthcare services that are able to respond to changing decisions over time.
Collapse
Affiliation(s)
- Rebecca Sheridan
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Alex G Smith
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Andrew Turner
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, UK
| | - Anne C Garry
- Department of Palliative Care, York Hospital, York, YO31 8HE, UK
| | - Russell Patmore
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull, HU16 5JQ, UK
| | - Martin R Howard
- Department of Haematology, York Hospital, York, YO31 8HE, UK
| | - Debra A Howell
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| |
Collapse
|
8
|
Tanzi S, Venturelli F, Luminari S, Merlo FD, Braglia L, Bassi C, Costantini M. Early palliative care in haematological patients: a systematic literature review. BMJ Support Palliat Care 2020; 10:395-403. [DOI: 10.1136/bmjspcare-2020-002386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/24/2020] [Accepted: 09/04/2020] [Indexed: 12/29/2022]
Abstract
BackgroundEarly 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 methodsA 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.ResultsA 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.ConclusionsStudies 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 numberCRD42020141322.
Collapse
|
9
|
Dowling M, Fahy P, Houghton C, Smalle M. A qualitative evidence synthesis of healthcare professionals' experiences and views of palliative care for patients with a haematological malignancy. Eur J Cancer Care (Engl) 2020; 29. [PMID: 32902114 PMCID: PMC7757223 DOI: 10.1111/ecc.13316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/30/2020] [Accepted: 08/07/2020] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Maura Dowling
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Paul Fahy
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Mike Smalle
- James Hardiman Library, National University of Ireland, Galway, Ireland
| |
Collapse
|