Palliative Care Issues for Transfusion-Dependent Patients #359

A multicentre survey on the perception of palliative care among health professionals working in haematology

PURPOSE

Patients with haematologic malignancies have less access to palliative care and are referred later than patients with solid tumours. We developed a survey to investigate this phenomenon, with the intention of analysing palliative care perceptions among health professionals who treat haematology patients and identifying barriers and facilitators to referrals to palliative care services.

METHODS

This was a multicentre exploratory descriptive web-based survey. A questionnaire was administered to 320 medical and nursing staff members from five Italian haematological units and San Marino's hospital to investigate their perception of palliative care. Quantitative and qualitative analyses were performed.

RESULTS

A total of 142/320 healthcare professionals completed the survey, achieving a 44% response rate. Most of the respondents supported the integration of haematology and palliative care and were aware of the role of palliative care. Despite this, only half had an in-hospital palliative care team, and only a few had previously attended a specific training course. The majority agreed with palliative care referral when the prognosis was less than 3 months or when the symptoms were incoercible and with blood transfusions even in the last stages of the disease. Many considered the presence of an in-hospital palliative care team or a case manager, as well as structured palliative care training, as fundamental facilitators of palliative care referrals.

CONCLUSION

These results showed that healthcare professionals in haematology generally hold a favourable attitude and a high interest in integrating palliative care into their patients' care. The low referral rate could depend on clinical, cultural, and organisational issues.

Transfusion practices in patients with advanced cancer: a retrospective study in a palliative care service

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.

[Study of representations of end-of-life platelet transfusion by its protagonists: Patients, nurses and hematologic oncologists]

INTRODUCTION

End-of-life platelet transfusion practice in onco-hematology is subjective and depends on representations shared by patients, nurses and hematologists. This study aims to describe these representations of platelet transfusion in a context of a severe and advanced hematologic malignancy through the social representation of its protagonists.

METHODS

A qualitative study, using the associative network method and including three groups of 15 participants (patients with an advanced hematologic malignancy, regularly transfused in platelet concentrates; nurses and hematologic oncologists) from four hematology centers was conducted between February and April 2019. Analysis was carried out using IraMuTeQ software.

RESULTS

Patients expect platelet transfusion to have a direct beneficial impact on their health and highlight human relations. Nurses aim at the patient's well-being, in his or her individuality, and at respecting the transfusion protocol. Physicians seek to relieve symptoms by taking into account a multitude of decision-making factors. The textual clustering method, nuances those previous results and individualizes four different orientations, independent of groups: dependency, singularity, subjectivity and neutrality.

DISCUSSION

The perception of the social representations related to platelet transfusion at the end-of-life should make it possible to adapt the discourse to the preferred orientation of the speaker and could be an asset in goals of care discussion with patients as well as with teams in charge of palliative care.

Transfusion as a Palliative Strategy

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.