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El-Jawahri A, Webb JA, Breffni H, Zimmermann C. Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers. Am Soc Clin Oncol Educ Book 2024; 44:e432196. [PMID: 38768404 DOI: 10.1200/edbk_432196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jason A Webb
- Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Hannon Breffni
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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2
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Kochovska S, Murtagh FEM, Agar M, Phillips JL, Dudgeon D, Lujic S, Johnson MJ, Currow DC. Creating more comparable cohorts in observational palliative care studies: A proposed framework to improve applicability and replicability of research. Palliat Med 2024; 38:617-624. [PMID: 38454317 PMCID: PMC11157983 DOI: 10.1177/02692163241234227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Palliative care is characterised by heterogeneous patient and caregiver populations who are provided care in different health systems and a research base including a large proportion of observational, mostly retrospective studies. The inherent diversity of palliative care populations and the often inadequate study descriptions challenge the application of new knowledge into practice and reproducibility for confirmatory studies. Being able to define systematically study populations would significantly increase their generalisability and effective translation into practice. PROPOSAL Based on an informal consensus process by active palliative care researchers challenged by this problem and a review of the current evidence, we propose an approach to creating more comparable cohorts in observational (non-randomised) palliative care studies that relies on defining the study population in relation to a fixed, well-defined event from which analyses are built ('anchoring'). In addition to providing a detailed and complete description of the study population, anchoring is the critical step in creating more comparable cohorts in observational palliative care studies. Anchoring can be done with respect to a single or multiple data points, and can support both prospective and retrospective data collection and analysis. DISCUSSION Anchoring the cohort to reproducible data points will help create more comparable cohorts in palliative care whilst mitigating its inherent heterogeneity. This, in turn, will help optimise the generalisability, applicability and reproducibility of observational palliative care studies to strengthen the evidence base and improve practice.
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Affiliation(s)
- Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Fliss EM Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Meera Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane L Phillips
- School of Nursing, Faculty of Health, University of Technology Queensland, Brisbane, QLD, Australia
| | - Deborah Dudgeon
- Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Sanja Lujic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
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3
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Pisarcik MJ, LeBlanc TW. Overcoming Transfusion Needs as a Barrier to Hospice Care for Patients With Blood Cancers. J Pain Symptom Manage 2024; 67:10-11. [PMID: 37924994 DOI: 10.1016/j.jpainsymman.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023]
Affiliation(s)
- Matthew J Pisarcik
- Department of Medicine (M.J.P.), Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine (T.W.L.), Duke University School of Medicine, Durham, North Carolina, USA; Duke Cancer Institute (T.W.L.), Durham, North Carolina, USA.
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Knight HP, Brennan C, Hurley SL, Tidswell AJ, Aldridge MD, Johnson KS, Banach E, Tulsky JA, Abel GA, Odejide OO. Perspectives on Transfusions for Hospice Patients With Blood Cancers: A Survey of Hospice Providers. J Pain Symptom Manage 2024; 67:1-9. [PMID: 37777022 PMCID: PMC10873003 DOI: 10.1016/j.jpainsymman.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 10/02/2023]
Abstract
CONTEXT Patients with blood cancers have low rates of hospice use. While lack of transfusion access in hospice is posited to substantially contribute to these low rates, little is known about the perspectives of hospice providers regarding transfusion access in hospice. OBJECTIVES To characterize hospice providers' perspectives regarding care for patients with blood cancers and transfusions in the hospice setting. METHODS In 2022, we conducted a cross-sectional survey of a sample of hospices in the United States regarding their experience caring for patients with blood cancers, perceived barriers to hospice use, and interventions to increase enrollment. RESULTS We received 113 completed surveys (response rate = 23.5%). Of the cohort, 2.7% reported that their agency always offers transfusions, 40.7% reported sometimes offering transfusions, and 54.9% reported never offering transfusions. In multivariable analyses, factors associated with offering transfusions included nonprofit ownership (OR 5.93, 95% CI, 2.2-15.2) and daily census >50 patients (OR 3.06, 95% CI, 1.19-7.87). Most respondents (76.6%) identified lack of transfusion access in hospice as a barrier to hospice enrollment for blood cancer patients. The top intervention considered as "very helpful" for increasing enrollment was additional reimbursement for transfusions (72.1%). CONCLUSION In this national sample of hospices, access to palliative transfusions was severely limited and was considered a significant barrier to hospice use for blood cancer patients. Moreover, hospices felt increased reimbursement for transfusions would be an important intervention. These data suggest that hospice providers are supportive of increasing transfusion access and highlight the critical need for innovative hospice payment models to improve end-of-life care for patients with blood cancers.
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Affiliation(s)
- Helen P Knight
- Department of Psychosocial Oncology and Palliative Care (H.P.K., J,A,T.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Caitlin Brennan
- Care Dimensions Inc. (C.B., S.L.H.), Boston, Massachusetts; Boston College Connell School of Nursing (C.B.), Chestnut Hill, Massachusetts
| | | | - Anna J Tidswell
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine (M.D.A.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kimberly S Johnson
- Division of Geriatrics (K.S.J.), Duke University Medical Center, Durham, North Carolina
| | - Edo Banach
- Manatt Health (E.B.), Washington, District of Columbia
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (H.P.K., J,A,T.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A Abel
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies (G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Oreofe O Odejide
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies (G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts.
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5
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Tanaka A, Fujita H, Ohashi K, Tsujikawa A, Uchiyama K, Ito T, Kawashima K, Kodama R, Mine T, Okuda M, Endoh T, Fukuyoshi Y, Kitazawa J, Sueoka E, Nagai K, Ishida A, Matsuzaki K, Kato Y, Takanashi K, Takahashi K. Home transfusions are implemented using diverse approaches in Japan. Vox Sang 2023; 118:938-946. [PMID: 37671662 DOI: 10.1111/vox.13518] [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] [Received: 04/12/2023] [Revised: 07/04/2023] [Accepted: 08/09/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Japan's ageing society has increased the need for home healthcare, including home transfusions. We hence aimed to elucidate the purpose and utilization of home transfusions in Japan, which has not been clarified to date. MATERIALS AND METHODS Clinics throughout Japan that provide home care and have experience in performing blood transfusions were surveyed. The study period was February to December 2019, and information of patients receiving home red blood cell transfusions, including patient background, pre-transfusion laboratory data and the purpose of the transfusions, was collected. RESULTS Haematological malignancies and solid tumours accounted for 70% of the patients' underlying diseases, with the former being significantly more common in urban areas. Regarding the purpose of the home transfusions, haematologists focused on symptom improvement, whereas gastroenterology surgeons focused on life support. Furthermore, maintenance of life was more likely to be the aim in the group of patients with the lowest level of activities of daily living. The main items that were significantly associated with a low haemoglobin level before transfusion included age ≥90 years and a gastroenterologist being the physician in charge. CONCLUSION Home transfusions were found to be performed in a restrictive and diverse manner in Japan. Life support is the second most common purpose of home transfusion in Japan, and optimizing effective home transfusion remains a challenge.
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Affiliation(s)
- Asashi Tanaka
- Department of Clinical Laboratory Medicine and Department of Transfusion Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hiroshi Fujita
- Department of Transfusion Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kota Ohashi
- TOTUS Home Care Clinic, Hemato-Homecare Network, Tokyo, Japan
| | | | | | - Tatsuya Ito
- Nishiosu Ito Internal Medicine and Department of Hematology, Hemato-Homecare Network, Aichi, Japan
| | | | | | - Takashi Mine
- Donated Blood Distribution Foundation, Tokyo, Japan
| | - Makoto Okuda
- Division of Blood Transfusion, Toho University Omori Medical Center, Tokyo, Japan
| | - Teruo Endoh
- Department of Clinical Laboratory Science, School of Medical Technology, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Youko Fukuyoshi
- Department of Transfusion Medicine and Cell Therapy, Kumamoto University Hospital, Kumamoto, Japan
| | - Junichi Kitazawa
- Division of Clinical Laboratory, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Eisaburo Sueoka
- Department of Laboratory Medicine, Saga University Hospital, Saga, Japan
| | - Kazuhiro Nagai
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Akaru Ishida
- Division of Transfusion Medicine and Cell Transplantation, Saitama Medical University International Medical Center, Saitama, Japan
| | | | - Yoko Kato
- Department of Transfusion Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Kazuo Takanashi
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Koki Takahashi
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
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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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Tanaka A, Fujita H, Ohashi K, Tsujikawa A, Uchiyama K, Ito T, Kawashima K, Kodama R, Mine T, Okuda M, Endoh T, Fukuyoshi Y, Kitazawa J, Sueoka E, Nagai K, Ishida A, Matsuzaki K, Kato Y, Takanashi K, Takahashi K. Management system of home transfusion in Japan: A nationwide survey in 2019. Vox Sang 2023; 118:59-67. [PMID: 36454538 DOI: 10.1111/vox.13380] [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: 04/20/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND AND OBJECTIVES In Japan, there are various opinions on the pros and cons of home transfusion because of safety concerns. We hence aimed to elucidate the safety and availability of home transfusion in Japan, which has not been clarified to date. MATERIALS AND METHODS Clinics throughout Japan that provide home care and have experience in performing blood transfusions were surveyed. The analysis period was February to December 2019. Basic information about the clinics, their collaboration system with core hospitals, storage method of red blood cells (RBCs) and the system for the management of patient information regarding transfusion reactions were investigated. RESULTS Detailed information was obtained regarding the implementation of home transfusions by 51 clinics. The proportion of home care clinics performing home transfusions was 17.6%, and they were more frequently performed in urban regions. Approximately half of the clinics collaborated with a core hospital for emergency responses to transfusion reactions. At 84% of the clinics, RBC units were stored in refrigerators that were not exclusively allocated to blood storage. Nurses and family members were involved as patient attendants in 83% and 77% of the home transfusions, respectively. No serious transfusion reactions were reported among the 150 patients in 2019, nor the 623 patients up to 2018. CONCLUSION From data on its availability and safety, home transfusions are considered to be in the developing phase in Japan. Increased cooperation between hospitals and clinics is crucial towards improving the home transfusion system in Japan in the future.
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Affiliation(s)
- Asashi Tanaka
- Department of Clinical Laboratory Medicine and Department of Transfusion Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hiroshi Fujita
- Department of Transfusion Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kota Ohashi
- TOTUS Home Care Clinic, Hemato-Homecare Network, Tokyo, Japan
| | | | | | - Tatsuya Ito
- Nishiosu Ito Internal Medicine and Department of Hematology, Hemato-Homecare Network, Aichi, Japan
| | | | | | - Takashi Mine
- Donated Blood Distribution Foundation, Tokyo, Japan
| | - Makoto Okuda
- Division of Blood Transfusion, Toho University Omori Medical Center, Tokyo, Japan
| | - Teruo Endoh
- Department of Clinical Laboratory Science, School of Medical Technology, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Youko Fukuyoshi
- Department of Transfusion Medicine and Cell Therapy, Kumamoto University Hospital, Kumamoto, Japan
| | - Junichi Kitazawa
- Division of Clinical Laboratory, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Eisaburo Sueoka
- Department of Laboratory Medicine, Saga University Hospital, Saga, Japan
| | - Kazuhiro Nagai
- Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - Akaru Ishida
- Division of Transfusion Medicine and Cell Transplantation, Saitama Medical University International Medical Center, Saitama, Japan
| | | | - Yoko Kato
- Department of Transfusion Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Kazuo Takanashi
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Koki Takahashi
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
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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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9
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Transfusion practices in patients with advanced cancer: a retrospective study in a palliative care service. Porto Biomed J 2022; 7:e195. [PMID: 37152079 PMCID: PMC10158856 DOI: 10.1097/j.pbj.0000000000000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/12/2022] [Accepted: 10/15/2022] [Indexed: 12/23/2022] Open
Abstract
Background Anemia is highly prevalent in patients with advanced cancer and adversely affects the quality of life. There are limited data on the frequency, clinical utility, and effectiveness of red blood cell (RBC) transfusions, and no randomized controlled clinical trials or clinical practice guidelines are available. The aim of this study was to evaluate clinician practices on RBC transfusion in an oncologic palliative care service and its impact on patients' symptoms, adverse events, and overall survival. Methods This is a retrospective analysis of all patients with advanced cancer who received RBC transfusions admitted for 3 years. Preblood counts, the reason for transfusion, subjective benefit, and objective outcomes were listed. Results We identified 179 patients who underwent RBC transfusions. The mean age was 67 years, and 60% were male. We found a total of 435 RBC units in 301 transfusion episodes. Asthenia/fatigue was the most frequent symptom (68%). The mean pretransfusion hemoglobin (Hb) was 6.85 g/dL, and 48% of patients had a Hb above 7 g/dL. The symptomatic benefit was achieved in 36% of patients. Adverse events were reported in 4%, with a 30-day survival rate of 57%. A statistically significant association was found between Eastern Cooperative Oncology Group performance status (ECOG-PS) and the symptomatic benefit (P = .005). Hb level pretransfusion, ECOG-PS, and symptomatic benefits with transfusions were significantly associated with survival. Conclusion This study suggests that patients with advanced cancer with a higher functioning level may benefit more from RBC transfusion. Post-transfusion symptomatic benefits and pretransfusion ECOG-PS and Hb levels are independent predictors of survival. Further studies are needed to develop validated measures of objective functional changes to evaluate transfusions' clinical impact and identify patients most likely to benefit from it.
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Seah DS, Wilcock A, Chang S, Sousa MS, Sinnarajah A, Teoh CO, Allan S, Chye R, Doogue M, Hunt J, Agar M, Currow DC. Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study. Palliat Med 2022; 36:1408-1417. [PMID: 36113139 DOI: 10.1177/02692163221122326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Paracentesis is commonly undertaken in patients with cancer-related ascites. AIM To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting. DESIGN Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner. SETTING/PARTICIPANTS Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50. RESULTS At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation. CONCLUSION Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.
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Affiliation(s)
- Davinia Se Seah
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wilcock
- Hayward House Specialist Palliative Care Unit, School of Clinical Oncology, University of Nottingham, Nottingham, England
| | - Sungwon Chang
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mariana S Sousa
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Richard Chye
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Doogue
- University of Otago - Christchurch & Canterbury District Health Board, Christchurch, New Zealand
| | - Jane Hunt
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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11
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Quinn KL, Hsu AT, Meaney C, Qureshi D, Tanuseputro P, Seow H, Webber C, Fowler R, Downar J, Goldman R, Chan R, McGrail K, Isenberg SR. Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital. Palliat Med 2021; 35:1671-1681. [PMID: 33781119 PMCID: PMC8532234 DOI: 10.1177/02692163211002045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking. AIM The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use. SETTINGS AND PARTICIPANTS We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died. RESULTS Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use. CONCLUSIONS Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, Toronto and Ottawa, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Amy T Hsu
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danial Qureshi
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Colleen Webber
- ICES, Toronto and Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Rob Fowler
- Tory Trauma Program, Sunnybrook Hospital, Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario
| | - James Downar
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Russell Goldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Raphael Chan
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
| | - Sarina R Isenberg
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Ottawa, ON, Canada
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12
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Garraud O. Transfusion at the border of the "intention-to-treat", in the very aged person and in palliative care: A debate. Transfus Clin Biol 2021; 28:367-369. [PMID: 34464710 DOI: 10.1016/j.tracli.2021.08.350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022]
Abstract
In both palliative care and in the very aged person i.e. at the end of life, transfusion aims at bringing supportive care; it has indeed no intention to treat. It can occasionally be compassionate as to bring oxygen to a patient or a resident in nursing home wishing to enjoy some exercise or entertainment. Transfusion in this condition is not consensual, for reasons that are medical and/or societal. The present essay aims at discussing the main options to provide transfusion in such extreme, though non-exceptional, conditions.
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Affiliation(s)
- O Garraud
- INSERM_U1059, Faculty of medicine of Saint-Etienne, University of Lyon, Saint-Étienne, France.
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13
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Polomeni A, Prod'homme C, Ainaoui M, Bellec A, Berr A, Bonneau J, Charbonnier A, Coiteux V, de Berranger E, Descamps T, Gire M, Goncalves M, Ruscassié A, Yakoub-Agha I, Borel C. [Palliative care in hematopoietic stem-cell transplanted patients: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2021; 108:S1-S9. [PMID: 34176584 DOI: 10.1016/j.bulcan.2021.01.019] [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: 12/11/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/17/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT), the only curative therapy for numerous hematological malignancies, carries a significant risk of morbidity and mortality. The patients and families' expectations regarding the procedure, the prognosis uncertainties, as well as the existence of potential new therapeutic possibilities, lead to frequent use of intensive care. Even though the transplant physicians are highly skilled in acute care, their knowledge of palliative approach is limited, making the use of palliative care insufficient and often late. By promoting reflection on the proportionality of care and the patients' quality of life, palliative care may contribute to the allo-HCT patients management. Nevertheless, obstacles to this approach remain. The objective of this work is to propose recommendations to promote the implementation of palliative care into transplant units.
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Affiliation(s)
- Alice Polomeni
- AP-HP, hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du Faubourg Saint-Antoine, 75011 Paris, France.
| | - Chloé Prod'homme
- CHRU de Lille, clinique de médecine palliative, hôpital Calmette, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - Malika Ainaoui
- CHRU de Lille, service des maladies du sang, avenue Michel-Polonovski, 59037 Lille cedex, France
| | - Adeline Bellec
- CHU de Rennes, service d'hématologie clinique, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France
| | - Aurélie Berr
- Institut de cancérologie Strasbourg Europe, service d'hématologie, 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg cedex, France
| | - Jacinthe Bonneau
- CHU de Rennes, hôpital Sud, service d'hématologie oncologie et greffe de moelle pédiatrique, 16, boulevard de Bulgarie, 35203 Rennes cedex 2, France
| | - Amandine Charbonnier
- CHU-groupe hospitalier Amiens-Sud, service d'hématologie clinique et thérapie cellulaire, 90054 Amiens cedex 1, France
| | - Valérie Coiteux
- CHRU de Lille, service des maladies du sang, avenue Michel-Polonovski, 59037 Lille cedex, France
| | - Eva de Berranger
- CHRU de Lille, hôpital Jeanne de Flandres, hématologie pédiatrique, avenue Eugène Avinée, 59037 Lille cedex, France
| | - Thomas Descamps
- CHRU de Lille, service des maladies du sang, avenue Michel-Polonovski, 59037 Lille cedex, France
| | - Marion Gire
- Institut de cancérologie Lucien Neuwirth, service d'hématologie, 104, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France
| | - Murielle Goncalves
- A.P.H.P., hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du Faubourg Saint-Antoine, 75011 Paris, France
| | - Agnès Ruscassié
- Institut universitaire du cancer de Toulouse, département des soins de support, 1, avenue Irène Joliot-Curie, 31059 Toulouse cedex, France
| | | | - Cécile Borel
- Institut universitaire du cancer de Toulouse, service d'hématologie, 1, avenue Irène Joliot-Curie, 31059 Toulouse cedex, France
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14
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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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15
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Cripe LD, Cottingham AH, Martin CE, Hoffmann ML, Sargent K, Baker LB. Bereaved Informal Caregivers Rarely Recall a Relationship Between Transfusions and Hospice in Acute Myeloid Leukemia. Am J Hosp Palliat Care 2021; 39:68-71. [PMID: 33926274 DOI: 10.1177/10499091211013290] [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: 11/16/2022] Open
Abstract
AIMS The inability to prescribe blood transfusions is a potential barrier to timely hospice enrollment for patients with blood cancers. The benefits and harms of transfusions near the end of life (EOL), however, are poorly characterized and patients' preferences are unknown. We sought to characterize the recollections of bereaved caregivers about the relationships between transfusions and hospice enrollment decisions. METHODS We recruited 18 bereaved caregivers of 15 decedents who died within 6-18 months of the interview. Interviews focused on caregivers' recollections of transfusion and hospice enrollment decisions. Transcripts were analyzed for themes. RESULTS We identified 2 themes. First, caregivers described that transfusions were necessary and the decisions to receive transfusions or not were deferred to the clinicians. Second, only 1 caregiver recalled transfusions as relevant to hospice decisions. In that instance there was a delay. Caregivers identified difficulties recognizing death was imminent, hope for miracles, and the necessity of accepting life was ending as more relevant barriers. CONCLUSIONS The results indicate clinicians' beliefs in transfusion at EOL may be a more relevant barrier to hospice enrollment than patients' preferences. Strategies to evaluate accurately and discuss the actual benefits and harms of transfusions at the EOL are necessary to advise patients and integrate their preferences into decisions.
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Affiliation(s)
- Larry D Cripe
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Caroline E Martin
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mary Lynn Hoffmann
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | - Katherine Sargent
- Indiana University Simon Cancer Center, 14686Indiana University School of Medicine, Indianapolis, IN, USA
| | - Layla B Baker
- 50826The Regenstrief Institute, Indianapolis, IN, USA
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16
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Kuczmarski TM, Odejide OO. Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close? Curr Hematol Malig Rep 2021; 16:117-125. [PMID: 33864180 DOI: 10.1007/s11899-021-00629-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death. RECENT FINDINGS Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.
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Affiliation(s)
- Thomas M Kuczmarski
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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17
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Yang SY, Park SK, Kang HR, Kim HL, Lee EK, Kwon SH. Haematological cancer versus solid tumour end-of-life care: a longitudinal data analysis. BMJ Support Palliat Care 2020:bmjspcare-2020-002453. [PMID: 33376113 DOI: 10.1136/bmjspcare-2020-002453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/14/2020] [Accepted: 11/20/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To explore differences in end-of-life healthcare utilisation and medication costs between patients with haematological malignancies and patients with solid tumours. METHODS Data on deceased patients with cancer were selected from the sample cohort data of health insurance claims from 2008 to 2015 in South Korea. They were categorised into two groups: patients with haematological malignancies and patients with solid tumours. Longitudinal data comprised the patient-month unit and aggregated healthcare utilisation and medication cost for 1 year before death. Healthcare utilisation included emergency room visits, hospitalisation and blood transfusions. Medication costs were subdivided into anticancer drugs, antibiotics, opioids, sedatives and blood preparation. Generalised linear mixed models were used to evaluate differences between the two groups and time trends. RESULTS Of the 8719 deceased patients with cancer, 349 died from haematological malignancies. Compared with solid tumours, patients with haematological malignancies were more likely to visit the emergency room (OR=1.36, 95% CI 1.10 to 1.69) and receive blood transfusions (OR=5.44, 95% CI 4.29 to 6.90). The length of hospitalisation of patients was significantly different (difference=2.49 days, 95% CI 1.75 to 3.22). Medication costs, except for anticancer treatment, increased as death approached. The costs of antibiotics and blood preparations were higher in patients with haematological malignancies than in those with solid tumours: 3.24 (95% CI 2.14 to 4.90) and 4.10 (95% CI 2.77 to 6.09) times higher, respectively. CONCLUSIONS Patients with haematological malignancies are at a higher risk for aggressive care and economic burden at the end of life compared with those with solid tumours. Detailed attention is required when developing care plans for end-of-life care of haematological patients.
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Affiliation(s)
- So-Young Yang
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea (the Republic of)
| | - Sun-Kyeong Park
- College of Pharmacy, Catholic University of Korea, Bucheon, Korea (the Republic of)
| | - Hye-Rim Kang
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea (the Republic of)
| | - Hye-Lin Kim
- College of Pharmacy, Sahmyook University, Nowon-gu, Seoul, Korea (the Republic of)
| | - Eui-Kyung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea (the Republic of)
| | - Sun-Hong Kwon
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea (the Republic of)
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18
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LeBlanc TW. Improving end-of-life care for patients with leukemia: is inpatient death the right measure? Leuk Lymphoma 2020; 61:2546-2548. [DOI: 10.1080/10428194.2020.1838510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Thomas W. LeBlanc
- Duke Cancer Institute, Durham, NC, USA
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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19
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Hunt J, Brown L, Fazekas B, Doogue M, Rowett D, Luckett T, Morgan D, Reed-Cox K, Sheehan C, Tuffin P, Currow DC. Evaluation of the IMPACCT Rapid Program: A Cross-Sectional Survey of International Site Investigators. J Palliat Med 2020; 23:1292-1293. [PMID: 33001746 DOI: 10.1089/jpm.2020.0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jane Hunt
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Linda Brown
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Belinda Fazekas
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Matt Doogue
- Curtin University, Bentley, Western Australia, Australia.,Wolfson Palliative Care Research Centre, University of Hull, Hull, England
| | - Debra Rowett
- Department of Medicine, University of Otago, Christchurch, New Zealand.,Department of Clinical Pharmacology, Canterbury District Health Board, Christchurch, New Zealand
| | - Tim Luckett
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Deidre Morgan
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Kate Reed-Cox
- Palliative and Supportive Services, Research Centre for Palliative Care, Death and Dying (RePaDD), Flinders University, College of Nursing and Health Sciences, Adelaide, South Australia, Australia
| | - Caitlin Sheehan
- Drug and Therapeutics Information Service (DATIS), Adelaide, South Australia, Australia
| | - Penny Tuffin
- Palliative Care Australia, Kingston, Australian Capital Territory, Australia
| | - David C Currow
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, New South Wales, Australia.,Australian national Palliative Clinical Studies Collaborative, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Calvary Heath Care Kogarah, New South Wales, Australia
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20
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Mohyuddin GR, Abbasi S, Ripp J, Singh A, Kambhampati S, McClune B. Patients with leukemia dying in the hospital: results of the national inpatient sample and a call to do better. Leuk Lymphoma 2020; 61:2760-2762. [PMID: 32552301 DOI: 10.1080/10428194.2020.1780585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - Saqib Abbasi
- Hematology-Oncology Fellowship, University of Kansas Cancer Center, Kansas City, KS, USA
| | - Jacob Ripp
- Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Anurag Singh
- Department of Hematological Malignancies and Cellular Therapeutic, University of Kansas, Kansas City, KS, USA
| | | | - Brian McClune
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, UT, USA
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21
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Odejide OO, Steensma DP. Patients with haematological malignancies should not have to choose between transfusions and hospice care. LANCET HAEMATOLOGY 2020; 7:e418-e424. [PMID: 32359453 DOI: 10.1016/s2352-3026(20)30042-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/11/2022]
Abstract
Hospice programmes are important for providing end-of-life care to patients with life-limiting illnesses. Hospice enrolment improves quality of life for patients with advanced cancer and reduces the risk of depression for caregivers. Despite the clear benefits of hospice care, patients with haematological malignancies have the lowest rates of enrolment among patients with any tumour subtype. Furthermore, when patients with haematological disorders do enrol into hospice care, they are more likely to do so within 3 days of death than are patients with non-haematological malignancies. Although reasons for low and late hospice use in this population are multifactorial, a key barrier is limited access to blood transfusions in hospice programmes. In this Viewpoint, we discuss the relationship between transfusion dependence and hospice use for patients with blood cancers. We suggest that rather than constraining patients into either transfusion or hospice models, policies that promote combining palliative transfusions with hospice services are likely to optimise end-of-life care for patients with haematological malignancies.
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Affiliation(s)
- Oreofe O Odejide
- Harvard Medical School, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - David P Steensma
- Harvard Medical School, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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22
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Storch EK, Custer BS, Jacobs MR, Menitove JE, Mintz PD. Review of current transfusion therapy and blood banking practices. Blood Rev 2019; 38:100593. [PMID: 31405535 DOI: 10.1016/j.blre.2019.100593] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/08/2019] [Accepted: 07/23/2019] [Indexed: 01/28/2023]
Abstract
Transfusion Medicine is a dynamically evolving field. Recent high-quality research has reshaped the paradigms guiding blood transfusion. As increasing evidence supports the benefit of limiting transfusion, guidelines have been developed and disseminated into clinical practice governing optimal transfusion of red cells, platelets, plasma and cryoprecipitate. Concepts ranging from transfusion thresholds to prophylactic use to maximal storage time are addressed in guidelines. Patient blood management programs have developed to implement principles of patient safety through limiting transfusion in clinical practice. Data from National Hemovigilance Surveys showing dramatic declines in blood utilization over the past decade demonstrate the practical uptake of current principles guiding patient safety. In parallel with decreasing use of traditional blood products, the development of new technologies for blood transfusion such as freeze drying and cold storage has accelerated. Approaches to policy decision making to augment blood safety have also changed. Drivers of these changes include a deeper understanding of emerging threats and adverse events based on hemovigilance, and an increasing healthcare system expectation to align blood safety decision making with approaches used in other healthcare disciplines.
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Affiliation(s)
| | - Brian S Custer
- UCSF Department of Laboratory Medicine, Blood Systems Research Institute, USA.
| | - Michael R Jacobs
- Department of Pathology, Case Western Reserve University, USA; Department of Clinical Microbiology, University Hospitals Cleveland Medical Center, USA.
| | - Jay E Menitove
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, USA
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23
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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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24
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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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25
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Timilsina S, Karki S, Timalsina S, Gautam A, Sharma S. Does packed red cell transfusion provide symptomatic benefits to cancer palliative patients?: a longitudinal study from a single private oncology center in Nepal. BMC Palliat Care 2019; 18:67. [PMID: 31387568 PMCID: PMC6685247 DOI: 10.1186/s12904-019-0454-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 07/31/2019] [Indexed: 11/20/2022] Open
Abstract
Background Palliative patients generally present with symptoms of dyspnea, easy fatigability, lethargy and feeling of being unwell which can broadly be attributed to one root cause: cancer-related anemia. So, packed red cell transfusion is often carried out aiming to improve patients’ functional status. Different cut off hemoglobin values have been suggested, with Hb < 9 g/dL the most commonly accepted. The present study aims at evaluating and comparing the benefits in subjective symptoms of fatigue and breathlessness among transfused and non-transfused palliative patients on Day 0 and Day 7. Methods Hemoglobin values, anemia related subjective symptoms of fatigue and breathlessness were recorded from 122 patients. The patients were re-evaluated on day-7 post-transfusion. The pre and post-transfusion symptomatic benefit was compared in both transfused and non-transfused palliative care patients. Results The currently practiced hemoglobin trigger for packed red cell transfusion is 10 g/dL. The units of packed red cell to be transfused was decided according to the hemoglobin values targeting the rise to > 10 g/dL. A mean 1.36 units were transfused. Statistically significant improvement was observed in patient reported symptoms of fatigue and breathlessness among both transfused and non-transfused palliative patients. Conclusion Anemic cancer palliative patients were found to benefit following packed red cell transfusion, suggesting a favorable association between the transfusion and patient-reported fatigue and dyspnea.
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Affiliation(s)
- Sameer Timilsina
- Department of Physiology, Tribhuvan University, Chitwan Medical College, Post Box No.: 42, Bharatpur-5, Chitwan, Nepal.
| | - Sirisa Karki
- Department of Pharmacology, Tribhuvan University, Chitwan Medical College, Bharatpur-5, Chitwan, Nepal
| | - Santosh Timalsina
- Department of Biochemistry, Tribhuvan University, Chitwan Medical College, Bharatpur-5, Chitwan, Nepal
| | - Aajeevan Gautam
- Department of Anatomy, Tribhuvan University, Chitwan Medical College, Bharatpur-5, Chitwan, Nepal
| | - Sabitri Sharma
- Palliative Care Unit, Nepal Cancer Hospital and Research Center, Harisiddhi, Lalitpur, Nepal
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St Lezin E, Karafin MS, Bruhn R, Chowdhury D, Qu L, Bialkowski W, Merenda S, D'Andrea P, McCalla AL, Anderson L, Keating SM, Stone M, Snyder EL, Brambilla D, Murphy EL, Norris PJ, Hilton JF, Spencer BR, Kleinman S, Carson JL. Therapeutic impact of red blood cell transfusion on anemic outpatients: the RETRO study. Transfusion 2019; 59:1934-1943. [PMID: 30882919 DOI: 10.1111/trf.15249] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with cancer or other diagnoses associated with chronic anemia often receive red blood cell (RBC) transfusion as outpatients, but the effect of transfusion on functional status is not well demonstrated. STUDY DESIGN AND METHODS To estimate the effect of transfusion on functional status and quality of life, we measured 6-minute walk test distance and fatigue- and dyspnea-related quality-of-life scores before and 1 week after RBC transfusion in 208 outpatients age ≥50 with at least one benign or malignant hematology/oncology diagnosis. To account for potential confounding effects of cancer treatment, patients were classified into two groups based on cancer treatment within 4 weeks of the study transfusion. Minimum clinically important improvements over baseline were 20 meters in walk test distance, 3 points in fatigue score, and 2 points in dyspnea score. RESULTS The median improvement in unadjusted walk test distance was 20 meters overall and 30 meters in patients not receiving recent cancer treatment. Fatigue scores improved overall by a median of 3 points and by 4 points in patients without cancer treatment. There was no clinically important change in dyspnea scores. In multiple linear regression analysis, patients who maintained hemoglobin (Hb) levels of 8 g/dL or greater at 1 week posttransfusion, who had not received recent cancer treatment, and who did not require hospitalization during the study showed clinically important increases in mean walk test distance. CONCLUSIONS Red blood cell transfusion is associated with a modest, but clinically important improvement in walk test distance and fatigue score outcomes in adult hematology/oncology outpatients.
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Affiliation(s)
- Elizabeth St Lezin
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California.,Department of Laboratory Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Matthew S Karafin
- Medical Sciences Institute (MSI), BloodCenter of Wisconsin, Milwaukee, Wisconsin
| | - Roberta Bruhn
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California.,Vitalant Research Institute, San Francisco, California
| | | | - Lirong Qu
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Walter Bialkowski
- Medical Sciences Institute (MSI), BloodCenter of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | - Lisa Anderson
- Medical Sciences Institute (MSI), BloodCenter of Wisconsin, Milwaukee, Wisconsin
| | | | - Mars Stone
- Vitalant Research Institute, San Francisco, California
| | | | | | - Edward L Murphy
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California.,Vitalant Research Institute, San Francisco, California
| | - Philip J Norris
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California.,Vitalant Research Institute, San Francisco, California
| | - Joan F Hilton
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | | | - Steven Kleinman
- University of British Columbia, Victoria, British Columbia, Canada
| | - Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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27
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Neoh K, Gray R, Grant-Casey J, Estcourt L, Malia C, Boland JW, Bennett MI. National comparative audit of red blood cell transfusion practice in hospices: Recommendations for palliative care practice. Palliat Med 2019; 33:102-108. [PMID: 30260291 PMCID: PMC6291900 DOI: 10.1177/0269216318801755] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Red blood cell transfusions are commonly used in palliative care to treat anaemia or symptoms caused by anaemia. In patients with advanced disease, there is little evidence of benefit to guide treatment decisions in the face of increased risk of harms. Aim: To determine national transfusion practice in hospices and compare this against National Institute for Health and Care Excellence and British Society of Haematology guidelines to develop recommendations to improve practice. Design and Setting: Prospective data collection on red blood cell transfusion practice in UK adult hospices over a 3-month census period. Results: A total of 121/210 (58%) hospices participated. A total of 465 transfusion episodes occurred in 83 hospices. Patients had a mean age of 71 years, and 96% had cancer. Mean pre-transfusion haemoglobin was 75 g/L (standard deviation = 11.15). Anaemia of chronic disease was the largest cause of anaemia (176; 38%); potentially amenable to alternative treatments. Haematinics were not checked in 70% of patients. Alternative treatments such as B12, folate and iron were rarely used. Despite transfusion-associated circulatory overload risk, 85% of patients were not weighed, and 84% had two or more units transfused. Only 83 (18%) patients had an improvement maintained at 30 days; 142 (31%) had <14 day improvement, and 50 (11%) had no improvement. A total of 150 patients (32%) were dead at 30 days. Conclusion: More rigorous investigation of anaemia, increased use of alternative therapies and more restrictive approach to red cell transfusions are recommended. Clinicians should discuss the limited benefit versus potentially higher risks with patients in hospice services to inform treatment decisions.
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Affiliation(s)
- Karen Neoh
- St Gemma’s Academic Unit of Palliative
Care, University of Leeds, Leeds, UK
| | - Ross Gray
- National Comparative Audit of Blood
Transfusion, NHS Blood and Transplant, Oxford, UK
| | - John Grant-Casey
- National Comparative Audit of Blood
Transfusion, NHS Blood and Transplant, Oxford, UK
| | - Lise Estcourt
- NHS Blood and Transplant, Oxford,
UK
- University of Oxford, Oxford, UK
| | | | - Jason W Boland
- Wolfson Centre for Palliative Care
Research, Hull York Medical School, University of Hull, Hull, UK
| | - Michael I Bennett
- St Gemma’s Academic Unit of Palliative
Care, University of Leeds, Leeds, UK
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Sirianni G, Perri G, Callum J, Gardner S, Berall A, Selby D. A Retrospective Chart Review of Transfusion Practices in the Palliative Care Unit Setting. Am J Hosp Palliat Care 2018; 36:185-190. [DOI: 10.1177/1049909118806456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: There remains limited data in the literature on the frequency, clinical utility and effectiveness of transfusions in palliative care, with no randomized controlled trials or clinical practice guidelines on this topic. There are no routinely accepted practices in place for the appropriate transfusion of blood products in this setting. Aim: The aim of this study was to retrospectively review all transfusions in the palliative care units of 2, tertiary care hospitals in Canada. The goals were to elucidate the frequency, indications, patient characteristics, and practices around this intervention. Design: Descriptive, retrospective chart review. Setting/Participants: The clinical charts of patients admitted to the palliative care unit and who obtained blood transfusions for the period of April 1, 2015, to March 31, 2017, were reviewed. All patients admitted who obtained a transfusion were included. There were no exclusion criteria. Results: Transfusions in the palliative care units were rare despite their availability (0.9% at Sunnybrook and 1.4% Baycrest) and were primarily given to patients with cancer. The main symptom issues identified for transfusion were fatigue and dyspnea. The majority of patients endorsed symptomatic benefit with minimal adverse reactions though pre- and post-transfusion assessment practices varied greatly between institutions. Conclusions: Transfusions in the palliative care units were infrequent, symptom targeted, and well tolerated, though the lack of standardized pre/post assessment tools limits any ability to draw conclusions about utility. Patients would benefit from additional research in this area and the development of clinical practice guidelines for transfusions in palliative care.
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Affiliation(s)
- Giovanna Sirianni
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Giulia Perri
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Baycrest Hospital, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Sandra Gardner
- Baycrest Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | | | - Debbie Selby
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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29
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LeBlanc TW, Egan PC, Olszewski AJ. Transfusion dependence, use of hospice services, and quality of end-of-life care in leukemia. Blood 2018; 132:717-726. [PMID: 29848484 PMCID: PMC6097134 DOI: 10.1182/blood-2018-03-842575] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/28/2018] [Indexed: 12/11/2022] Open
Abstract
Hospice provides high-quality end-of-life care, but patients with leukemias use hospice services less frequently than those with solid tumors. Transfusion dependence (TD) may hinder or delay enrollment, because hospice organizations typically disallow transfusions. We examined the association between TD and end-of-life outcomes among Medicare beneficiaries with leukemia. From the Surveillance, Epidemiology, and End Results-Medicare database, we selected beneficiaries with acute and chronic leukemias who died in 2001-2011. We defined TD as ≥2 transfusions within 30 days before death or hospice enrollment. End points included hospice enrollment and length of stay, reporting relative risk (RR) adjusted for key covariates. Among 21 033 patients with a median age of 79 years, 20% were transfusion dependent before death/hospice enrollment. Use of hospice increased from 35% in 2001 to 49% in 2011. Median time on hospice was 9 days and was shorter for transfusion-dependent patients (6 vs 11 days; P < .001). Adjusting for baseline characteristics, TD was associated with a higher use of hospice services (RR, 1.08; 95% confidence interval [CI], 1.04-1.12) but also with 51% shorter hospice length of stay (RR, 0.49; 95% CI, 0.44-0.54). Hospice enrollees had a lower likelihood of inpatient death and chemotherapy use and lower median Medicare spending at end-of-life, regardless of TD status. In conclusion, relatively increased hospice use combined with a markedly shorter length of stay among transfusion-dependent patients suggests that they have a high and incompletely met need for hospice services and that they experience a barrier to timely referral. Policy solutions supporting palliative transfusions may maximize the benefits of hospice for leukemia patients.
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Affiliation(s)
- Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Pamela C Egan
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI; and
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
| | - Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI; and
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
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30
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Raval JS, Cooling LL. Red blood cell transfusion in palliative care: what are we doing and why are we doing it? Transfusion 2018; 58:3-4. [DOI: 10.1111/trf.14437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Jay S. Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill NC
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