A Cohort Study of Patient-Reported Outcomes and Healthcare Utilization in Acute Myeloid Leukemia Patients Receiving Active Cancer Therapy in the Last Six Months of Life

Impact of Palliative Care Referral on End-of-Life Outcomes for Patients With Hematologic Malignancy

CONTEXT

Compared to patients with solid malignancies, less is known about the role of palliative care in patients with hematologic malignancies, leading to underutilization of palliative care.

OBJECTIVES

Evaluate the timing and impact of palliative care referrals on end-of-life outcomes over a 5-year period with intent to improve the utilization of palliative care in patients with advanced hematologic malignancies.

METHODS

A retrospective cohort of patients from an urban, NCI-designated comprehensive cancer center, aged 18 years and older with a diagnosis of an advanced hematologic malignancy were separated into groups of early, late, very late, or no specialty palliative care. Logistic regression models were constructed to examine variables associated with timing of palliative care referral. Groups were compared using the Kruskal Wallis test and Dunn's test with a Bonferroni correction method.

RESULTS

222 patients with advanced hematologic malignancies who died between July 1, 20218 and June 30, 2023 were included. 50 (23%), 41 (18%), and 51 (23%) patients received an early, late, and very late palliative care referral, respectively and 80 (36%) patients did not receive a palliative care referral. There was a significantly high completion of ACP documentation among the palliative care cohorts. There was no significant difference among all cohorts in end-of-life outcomes in the last 14 or 30 days of life.

CONCLUSION

ACP documentation improved with palliative care, however, end-of-life outcomes did not. These results are likely due to the majority of late, inpatient palliative care referrals. Future studies with targeted interventions are needed to improve these outcomes.

Top Ten Tips Palliative Care Clinicians Should Know About Acute Myeloid Leukemia

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.

Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre

BACKGROUND

Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand.

AIMS

This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available.

METHODS

One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input.

RESULTS

During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively.

CONCLUSIONS

The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.

Experience of Care Among Adults With Acute Leukemia Near the End of Life: A Scoping Review

Background: Acute leukemia is a cancer of the blood and bone marrow with a high symptom burden and a high mortality rate in adults. The quality of end-of-life care among this patient population is deemed to be low based on health care administrative data, though the patient experience is not included in this evaluation. Objective: This scoping review aims at exploring and mapping the current research literature on the experience of care among adults with incurable acute leukemia near the end of life. Design: The JBI framework guided our scoping review, and the protocol was prospectively registered in the Open Science Forum. Results: A total of 5661 unique articles were screened for title and abstract, and 44 were selected for full text. After a manual search, five studies published in seven articles were selected for data extraction, including three qualitative and two quantitative studies. Two studies used family caregivers as patient proxies, two studies engaged patients directly, whereas one study obtained data from patients and family caregivers. Patient care in acute settings was reported in all studies, with most patients dying in acute care settings. Patients and family caregivers often valued an open and honest approach, with sufficient time for dialogue with their providers. Discussions about prognosis, palliative care, and hospice care were often late or incomplete. The medicalization of end-of-life care, including intensive care unit admissions and invasive medical procedures, were viewed as the norm by some providers, though perceived as distressing for both patients and their loved ones. Conclusions: Adults with acute leukemia face significant challenges in accessing high-quality end-of-life care brought about by the complex nature of their disease and its treatment. A systematic exploration of the end-of-life experience among these patients through direct patient engagement or by way of patient reporting proxies is needed.

Xerostomia in patients with advanced cancer: a scoping review of clinical features and complications

BACKGROUND

The aim of this project was to review the literature on dry mouth / xerostomia in patients with advanced cancer, with the objectives being to determine its prevalence, clinical features, and complications.

METHODS

Standard methodology was used to conduct this scoping review. Detailed searches of the Medline, Embase, CINAHL, and PsycInfo databases were conducted to identify relevant studies: eligible studies had to include patients with advanced cancer, and to contain details of clinical features and/or complications of xerostomia. Commercial bibliographic / systematic review software was used to support the process.

RESULTS

Forty-three studies were discovered from the database and hand searches. The studies included 23 generic symptom studies, eight "symptom cluster" studies, nine oral symptom / problem studies, and three xerostomia-specific studies. In depth data is described on the clinical features and complications of xerostomia, and on the "symptom clusters" including xerostomia, in this cohort of patients.

CONCLUSION

This review discovered a relatively small number of focused studies (involving a similarly small number of patients). Nonetheless, it demonstrates that xerostomia is a very common problem in patients with advanced cancer and is often associated with significant morbidity (and impairment of quality of life).

Innovations for the integration of palliative care for hematologic malignancies

Specialist palliative care provides additional support to facilitate living well with a serious illness, like cancer, even while pursuing disease-directed therapy. For patients with hematologic malignancies, integrated specialist palliative care improves symptom burden, mood, and quality of life, with benefits even extending to caregivers. Despite this, patients with hematologic malignancies continue to have significant unmet palliative care needs and typically access palliative care late in their disease trajectories, if at all. In this paper, we will define specialist palliative care and review its benefits for patients with hematologic malignancies. We will discuss the unmet palliative care needs of this patient population and the barriers to integrating palliative care and oncologic care. Finally, we will explore innovations and areas of future research to enhance and optimize palliative care integration into usual cancer care treatment for patients with hematologic malignancies. We will explore the importance of ongoing clinical trials that are examining the correct "dose" of palliative care; the use of technology and telehealth; and the use of novel treatments for this patient population. Together, we will consider innovative avenues to provide palliative care to patients with hematologic malignancies and their caregivers.

Palliative Care in Patients with Hematological Malignancies

Palliative care is an attempt to improve the quality of life of patients and their relatives who have lost the chance of a cure. Interventions to improve the quality of life of patients include physical, mental, and psychosocial problems. It is known that symptoms such as pain, fatigue, loss of appetite, and feeling unwell, which often cause deterioration in quality of life, are improved with palliative care support. It is seen that palliative care support, which is mostly recommended in the end-of-life period of patients with solid tumors, is not recommended for patients with hematological malignancies. In fact, patients with hematological malignancies face physical, mental, and economic difficulties due to the intense treatment protocols required for their disease and the side effects of the treatments. Compared to patients with solid tumors, patients with hematological malignancies have a higher frequency of hospitalization and intensive care unit admission. For these reasons, our aim is to define the palliative care needs of patients with hematologic malignancies, understand the barriers to palliative care and end-of-life care, and offer solutions to improve the quality of life and care of patients with hematologic malignancies.

Early Palliative Care in Acute Myeloid Leukemia

Background: Several novel targeted therapies seem to improve the outcome of acute myeloid leukemia (AML) patients. Nonetheless, the 5-year survival rate remains below 40%, and the trajectory of the disease remains physically and emotionally challenging, with little time to make relevant decisions. For patients with advanced solid tumors, the integration of early palliative care (EPC) with standard oncologic care a few weeks after diagnosis has demonstrated several benefits. However, this model is underutilized in patients with hematologic malignancies. Methods: In this article, we analyze the palliative care (PC) needs of AML patients, examine the operational aspects of an integrated model, and review the evidence in favor of EPC integration in the AML course. Results: AML patients have a high burden of physical and psychological symptoms and high use of avoidant coping strategies. Emerging studies, including a phase III randomized controlled trial, have reported that EPC is feasible for inpatients and outpatients, improves quality of life (QoL), promotes adaptive coping, reduces psychological symptoms, and enhances the quality of end-of-life care. Conclusions: EPC should become the new standard of care for AML patients. However, this raises issues about the urgent development of adequate programs of education to increase timely access to PC.

Factors Associated with Health Care Utilization at the End of Life for Patients with Acute Myeloid Leukemia

Background: Patients (≥60 years) with acute myeloid leukemia (AML) often receive intense health care utilization at the end of life (EOL). However, factors associated with their health care use at the EOL are unknown. Methods: We conducted a secondary analysis of 168 deceased patients with AML within the United States. We assessed quality of life (QOL) (Functional-Assessment-Cancer-Therapy-Leukemia), and psychological distress (Hospital-Anxiety-and-Depression Scale [HADS]; Patient-Health-Questionnaire-9 [PHQ-9]) at diagnosis. We used multivariable logistic regression models to examine the association between patient-reported factors and the following outcomes: (1) hospitalizations in the last 7 days of life, (2) receipt of chemotherapy in the last 30 days of life, and (3) hospice utilization. Results: About 66.7% (110/165) were hospitalized in the last 7 days of life, 51.8% (71/137) received chemotherapy in the last 30 days of life, and 40.7% (70/168) utilized hospice. In multivariable models, higher education (odds ratio [OR] = 1.54, p = 0.006) and elevated baseline depression symptoms (PHQ-9: OR = 1.09, p = 0.028) were associated with higher odds of hospitalization in the last seven days of life, while higher baseline QOL (OR = 0.98, p = 0.009) was associated with lower odds of hospitalization at the EOL. Higher baseline depression symptoms were associated with receipt of chemotherapy at the EOL (HADS-Depression: OR = 1.10, p = 0.042). Higher education was associated with lower hospice utilization (OR = 0.356, p = 0.024). Conclusions: Patients with AML who are more educated, with higher baseline depression symptoms and lower QOL, were more likely to experience high health care utilization at the EOL. These populations may benefit from interventions to optimize the quality of their EOL care.

Early palliative/supportive care in acute myeloid leukaemia allows low aggression end-of-life interventions: observational outpatient study

OBJECTIVES

Early palliative supportive care has been associated with many advantages in patients with advanced cancer. However, this model is underutilised in patients with haematological malignancies. We investigated the presence and described the frequency of quality indicators for palliative care and end-of-life care in a cohort of patients with acute myeloid leukaemia receiving early palliative supportive care.

METHODS

This is an observational, retrospective study based on 215 patients consecutively enrolled at a haematology early palliative supportive care clinic in Modena, Italy. Comprehensive hospital chart reviews were performed to abstract the presence of well-established quality indicators for palliative care and for aggressiveness of care near the end of life.

RESULTS

131 patients received a full early palliative supportive care intervention. All patients had at least one and 67 (51%) patients had four or more quality indicators for palliative care. Only 2.7% of them received chemotherapy in the last 14 days of life. None underwent intubation or cardiopulmonary resuscitation and was admitted to intensive care unit during the last month of life. Only 4% had either multiple hospitalisations or two or more emergency department access. Approximately half of them died at home or in a hospice. More than 40% did not receive transfusions within 7 days of death. The remaining 84 patients, considered late referrals to palliative care, demonstrated sensibly lower frequencies of the same indicators.

CONCLUSIONS

Patients with acute myeloid leukaemia receiving early palliative supportive care demonstrated high frequency of quality indicators for palliative care and low rates of treatment aggressiveness at the end of life.

Understanding the impact of clinical characteristics and healthcare utilizations on suicide among cancer sufferers: a case-control study in Hong Kong

Background

Few studies have investigated whether hospital utilization patterns of cancer sufferers are associated with their suicide. This study aims to explore whether clinical profiles and healthcare utilization patterns are related to suicide among cancer sufferers.

Methods

Verified suicide cases with cancer (2012-2016) were identified. Each case was matched with two non-suicide controls suffering cancer, by birthyear, sex, and admission year. Cancer-related information, physical and psychiatric comorbidities, opioid-based painkiller usage, the number and length of inpatient admissions, and the number of outpatient and Accident & Emergency (A&E) attendances, in the six months leading up to the suicide, were identified. Conditional logistic regression models were constructed to explore the influence of clinical profiles and hospital utilization on suicide. These models were stratified by age and cancer stage.

Outcomes

383 cases and 766 controls were included in the analyses. Overall, younger age, metastasis/recurrent status, suffering head and neck cancer, having psychiatric comorbidities, using opioid-based painkillers, and high frequency of A&E attendances and inpatient admissions increased the odds of suicide. Being diagnosed with liver cancer, consuming high numbers of outpatient attendances, and high numbers of inpatient days decreased the odds of suicide. Stratified analyses confirmed the influence of young age and metastatic/recurrent cancer status on risk of suicide.

Interpretations

Suicidal cancer sufferers had distinctive clinical profiles and hospital utilization patterns. Detecting and mitigating suicidal risk should be incorporated as an important component in treatment of cancer sufferers in the clinical setting.

Funding

Li Ka Shing Foundation and Hong Kong Research Grants Council

Palliative Care Service Utilization and Advance Care Planning for Adult Glioblastoma Patients: A Systematic Review

Glioblastoma (GBM) has a median overall survival of 16-21 months. As patients with GBM suffer concurrently from terminal cancer and a disease with progressive neurocognitive decline, advance care planning (ACP) and palliative care (PC) are critical. We conducted a systematic review exploring published literature on the prevalence of ACP, end-of-life (EOL) services utilization (including PC services), and experiences among adults with GBM. We searched from database inception until 20 December 2020. Preferred reporting items for systematic reviews guidelines were followed. Included studies were assessed for quality using the Newcastle-Ottawa Scale. The 16 articles were all nonrandomized studies conducted in six countries with all but two published in 2014 or later. ACP documentation varied from 4-55%, PC referral was pursued in 39-40% of cases, and hospice referrals were made for 66-76% of patients. Hospitalizations frequently occurred at the EOL with 20-56% of patients spending over 25% of their overall survival time hospitalized. Many GBM patients do not pursue ACP or have access to PC. There is a dearth of focused and high-quality studies on ACP, PC, and hospice use among adults with GBM. Prospective studies that address these and additional aspects related to EOL care, such as healthcare costs and inpatient supportive care needs, are needed.

Unmet Supportive Care Needs of Patients with Hematological Malignancies: A Systematic Review

Hematological malignancies require intensive and long-term treatment, which brings a significant burden on patients, leading to unmet supportive care needs. The purpose of this review was to investigate the unmet supportive care needs of patients with hematological malignancies during and after active treatment as well as the factors that affect them. A systematic bibliographic search was carried out in the PubMed database for English articles published between 2009 and 2020 according to the Preferred Reporting Items for Systematic Reviews guidelines and under the terms: "unmet needs", "supportive care", "hematological malignancy" and "hematological cancer." Twenty studies were evaluated and reviewed. Hierarchical frequently reported unmet supportive care needs were informational, emotional, physical, daily living/practical (accessibility, transportation, and financial problems), and family life/relational needs. In particular, patients with multiple myeloma most frequently reported unmet needs at the informational, physical, emotional, and daily living/practical domain. Patients with myelodysplastic syndromes reported physical, emotional, practical, and relational needs. Patients with leukemia and lymphoma rated their needs as informational, physical, psychological, daily living, and sexual. Sexual and spiritual unmet needs were reported at a low level. Predictive indicators for increased unmet supportive care needs were the type of the hematological malignancy, younger age, marital status, female gender, monthly income, coexistence of anxiety and depression, and altered quality of life. To conclude with, the literature reports a significant number of unmet supportive care needs in patients with hematological malignancies, whose frequency and intensity were influenced by a variety of factors. However, the large heterogeneity of studies (design, sample, and needs assessment tools) makes the generalization of the results difficult.

[Palliative care medical consultation in a hematology department. Feedback and critical reflection on a year of practice]

INTRODUCTION

Patients with hematological malignancies have less access to palliative care than other cancer patients, and benefit from it later in the course of their disease, though symptom burden is just as heavy.

METHODS

We created a specialized outpatient palliative care consultation in the hematology department to improve the quality of patient management and enhance cooperation with hematologists.

RESULTS

We found that though patient characteristics and survival were extremely variable, they all had in common a need for symptom management and care coordination. As a result of the consultation, hematology teams called upon a specialized palliative care multidisciplinary team more often to meet patients hospitalized within their departments, and more patients with hematological malignancies hemopathies were hospitalized in palliative care units.

DISCUSSION

We describe the benefits that can be anticipated when collaboration increases between hematology and palliative care, including early on in the course of disease. It is now up to policy-makers to establish priorities regarding the allocation of health resources, in particular regarding end-of-life. This requires identifying patient needs, optimizing patient access to specialized palliative care, and improving the pertinence of palliative care interventions as they cannot be generalized.

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BACKGROUND

Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.

MATERIALS AND METHODS

We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services.

RESULTS

We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.

CONCLUSION

"Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

IMPLICATIONS FOR PRACTICE

Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

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

BACKGROUND AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Perspectives Regarding Hospice Services and Transfusion Access: Focus Groups With Blood Cancer Patients and Bereaved Caregivers

CONTEXT

Patients with blood cancers have low rates of timely hospice use. Barriers to hospice use for this population are not well understood. Lack of transfusion access in most hospice settings is posited as a potential reason for low and late enrollment rates.

OBJECTIVES

We explored the perspectives of patients with blood cancers and their bereaved caregivers regarding the value of hospice services and transfusions.

METHODS

Between June 2018 and January 2019, we conducted three focus groups with blood cancer patients with an estimated life expectancy of six months or less and two focus groups with bereaved caregivers of patients with blood cancers. We asked participants their perspectives regarding quality of life (QOL) and about the potential association of traditional hospice services and transfusions with QOL. A hematologic oncologist, sociologist, and qualitatively trained research assistant conducted thematic analysis of the data.

RESULTS

Twenty-seven individuals (18 patients and nine bereaved caregivers) participated in the five focus groups. Participants identified various QOL domains that were important to them but focused largely on a desire for energy to maintain physical/functional well-being. Participants considered transfusions a high-priority service for their QOL. They also felt that standard hospice services were important for QOL. Bereaved caregivers reported overall positive experiences with hospice.

CONCLUSION

Our analysis suggests that although patients with blood cancers value hospice services, they also consider transfusions vital to their QOL. Innovative care delivery models that combine the elements of standard hospice services with other patient-valued services like transfusions are most likely to optimize end-of-life care for patients with blood cancers.

Validation of the Functional Assessment of Cancer Therapy-Leukemia instrument in patients with acute myeloid leukemia who are not candidates for intensive therapy

BACKGROUND

The objective of this study was to validate the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) in patients with acute myeloid leukemia (AML) who are not candidates for intensive therapy.

METHODS

A sample of 317 patients with AML who were not eligible for intensive chemotherapy completed the FACT-Leu and EuroQol 5-Dimension (EQ-5D) measures (Utility Index and Visual Analogue Scale) every 28 days until the end of treatment. Internal consistency reliability was estimated with Cronbach's α. Concurrent validity was examined with correlations between FACT-Leu and EQ-5D scales, and known-groups validity was examined by determining whether FACT-Leu scales distinguished between Eastern Cooperative Oncology Group (ECOG) performance status ratings (PSRs) and between maximum adverse event toxicities at the baseline. This study examined responsiveness to change by anchoring change in the FACT-Leu scales to a 0.10 change in the EQ-5D Health Utility Index.

RESULTS

Cronbach's α usually exceeded the threshold for good (≥0.80) or excellent reliability (≥0.90). Correlations between FACT-Leu and EQ-5D scales were moderate (r > 0.50) or high (r > 0.70). FACT-Leu scales distinguished between ECOG PSR groups with large effect sizes for an ECOG PSR of 0 versus an ECOG PSR of 2 (0.50 ≤ d < 0.80). In addition, Functional Assessment of Cancer Therapy-General, Additional Concerns, FACT-Leu Total, and Trial Outcomes Index scales distinguished between patients with grade 3 or lower maximum adverse event toxicities and those with maximum adverse event toxicities higher than grade 3, but effect sizes were small (d < 0.50). Finally, FACT-Leu scale coefficients for a 0.10 change in the 5-level version of the EQ-5D HUI ranged between -0.01 and 4.30.

CONCLUSIONS

The FACT-Leu is a suitable outcome measure for AML clinical trials among patients not eligible for intensive therapy, and it may have value for clinical monitoring.

Palliative and End-of-Life Care for Patients With Hematologic Malignancies

Hematologic malignancies are a heterogeneous group of diseases with unique illness trajectories, treatment paradigms, and potential for curability, which affect patients' palliative and end-of-life care needs. Patients with hematologic malignancies endure immense physical and psychological symptoms because of both their illness and often intensive treatments that result in significant toxicities and adverse effects. Compared with patients with solid tumors, those with hematologic malignancies also experience high rates of hospitalizations, intensive care unit admissions, and in-hospital deaths and low rates of referral to hospice as well as shorter hospice length of stay. In addition, patients with hematologic malignancies harbor substantial misperceptions about treatment risks and benefits and frequently overestimate their prognosis. Even survivors of hematologic malignancies struggle with late effects, post-treatment complications, and post-traumatic stress symptoms that can significantly diminish their quality of life. Despite these substantial unmet needs, specialty palliative care services are infrequently consulted for the care of patients with hematologic malignancies. Several illness-specific, cultural, and system-based barriers to palliative care integration and optimal end-of-life care exist in this population. However, recent evidence has demonstrated the feasibility, acceptability, and efficacy of integrating palliative care to improve the quality of life and care of patients with hematologic malignancies and their caregivers. More research is needed to develop and test population-specific palliative and supportive care interventions to ensure generalizability and to define a sustainable clinical delivery model. Future work also should focus on identifying moderators and mediators of the effect of integrated palliative care models on patient-reported outcomes and on developing less resource-intensive integrated care models to address the diverse needs of this population.

Integration of Palliative Care into Acute Myeloid Leukemia Care

OBJECTIVE

To provide an overview of the past, present, and future of the integration of palliative care services for patients with hematologic malignancies, such as acute myeloid leukemia (AML).

DATA SOURCES

Published literature as indexed in Medline, relevant guideline documents, textbooks, and clinical experience.

CONCLUSION

Patients with acute leukemias have substantial palliative care needs that often go unmet with standard oncology care. Evidence shows that the early integration of specialist palliative care into standard oncology care improves patient-centered outcomes among those with advanced solid tumors. Emerging evidence supports similar benefits among hospitalized patients with hematologic malignancies undergoing stem cell transplantation, and additional trials are underway to further test palliative care interventions in patients with AML.

IMPLICATIONS FOR NURSING PRACTICE

By better understanding the palliative care needs of patients with AML and the evidence of integration with standard oncologic care, patients with leukemias may be more likely to receive early integrated palliative care.

Hemato-oncology and palliative care teams: is it time for an integrated approach to patient care?

PURPOSE OF REVIEW

Integrated palliative care for those with advanced solid tumors yields significant benefits in patient and caregiver outcomes. However, most palliative care clinical trials have excluded patients with hematologic malignancies. There is growing interest in whether integrated palliative care may yield similar benefits in hematologic malignancy patients and caregivers, but there has been little direct evidence of benefit in this population. This review summarizes new data on palliative care issues in hematologic malignancies, published in the preceding 12 months.

RECENT FINDINGS

Most newly published evidence on this topic from the last year is descriptive of unmet needs, poor end-of-life care outcomes or unique differences and issues posed by hematologic malignancies as compared to solid tumors. A few articles describe models of collaborative care in hematologic malignancies, and just one describes the impact of an integrated palliative care intervention on patient and caregiver outcomes. Several studies point to transfusions as a unique and problematic barrier to high-quality end-of-life care in hematologic malignancies.

SUMMARY

Recent evidence confirms that hematologic malignancy patients have unique and often unmet palliative care needs, and also have worse end-of-life outcomes. More work is needed to develop and test integrated palliative care interventions in this population.

Symptoms, Mobility and Function, and Quality of Life in Adults With Acute Leukemia During Initial Hospitalization

OBJECTIVES

To examine longitudinal symptoms, mobility and function, and quality of life (QOL) in adults newly diagnosed with acute leukemia.

SAMPLE & SETTING

55 adults undergoing induction chemotherapy at the University of North Carolina Lineberger Comprehensive Cancer Center and the Duke Cancer Institute.

METHODS & VARIABLES

A prospective, longitudinal study with measures of mobility and function, global physical and mental health, cancer-related fatigue, anxiety, depression, sleep disturbance, pain intensity, and leukemia-specific QOL was conducted. Data were analyzed using descriptive statistics, linear mixed modeling, and one-way analysis of variance.

RESULTS

49 adults with acute leukemia completed assessments during hospitalizations. Global mental health and pain intensity did not change significantly. Global physical health significantly improved. Fatigue, anxiety, depression, and sleep disturbance decreased significantly. QOL increased significantly.

IMPLICATIONS FOR NURSING

The significant decrease in anxiety and fatigue during hospitalization may be attributable to understanding of the disease process, familiarity with the staff, and ability to communicate concerns.