Specific challenges in end-of-life care for patients with hematological malignancies

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.

Clinical Features of Patients With Hematological Malignancies Treated at the Palliative Care Unit

Background

In Japan, the number of patients with aggressive hematological malignancies (PHMs) admitted at the palliative care unit (PCU) in their end-of-life (EOL) stage was fewer than that of patients with solid tumors due to several reasons. The assessment of patient characteristics and the methods of survival prediction among PHMs in the EOL stage are warranted.

Objectives

This study aimed to identify the current medical status and the method of survival prediction among PHMs treated at the PCU.

Setting/Subjects/Measurements

We retrospectively analyzed the clinical data of 25 PHMs treated at our PCU between January 2017 and December 2020. The association between survival time and the palliative prognostic score (PAP) and palliative prognostic index (PPI) was analyzed.

Results

The average age of the PHMs was higher than that of patients with lung cancer as a control. The median survival time of the PHMs was shorter than the control group. Most PHMs could not receive standard chemotherapy, and the most common cause of death was disease-related organ failure. Significant associations were observed between the survival time and each PAP/PPI value in patients with malignant lymphoma, but not in those with leukemia.

Conclusion

The PHMs in the PCU had a lower median survival time than the control group. These results were induced by the result of patient selection to avoid treatment-related severe toxicity. The survival prediction using the PAP and PPI was less accurate in patients with leukemia.

Knowledge, feelings, and willingness to use palliative care in cancer patients with hematologic malignancies and solid tumors: a prospective, cross-sectional study in a comprehensive cancer center in Germany

PURPOSE

Patients with hematologic malignancies (HM) receive palliative care (PC) less often and later than patients with solid tumors (ST). Patients' lack of knowledge about PC and negative feelings about PC are barriers to their willingness to use PC. Is there a difference between patients with HM and ST in their knowledge and willingness to use PC?

METHODS

Two hundred ten patients (85 HM, 125 ST) from an oncology day clinic at a university hospital participated in this cross-sectional, questionnaire-based survey.

RESULTS

Patients with HM and ST had high knowledge and mainly positive feelings about PC. More than half of the patients answered that they would feel reassured by the use of PC, and one-third would feel anxious or hopeless. The majority of patients (58.3%) were willing to use PC. There are no significant differences between patients with HM and ST. In multiple regression analysis, perceived chance of cure and feelings of reassurance and anxiety are associated with willingness to use PC, but not with the HM/ST disease group. More than half (53.9%) of the participants would like the treating physician to choose the timing of a discussion about PC.

CONCLUSION

Our study shows a high level of knowledge and relatively positive feelings of patients about PC, with no differences between patients with HM or ST. They expect their treating physician to initiate communication about PC. Communication should include the patient's feelings about PC and their chances of a cure.

Doing palliative care research on hematologic cancer patients: A realist synthesis of literature and experts’ opinion on what works, for whom and in what circumstances

Background

Research in PC (Palliative Care) is frequently challenging for patient’s frailty, study design, professional misconceptions, and so on. Little is known about specificity in PC research on Hematologic cancer patients, who have distinct characteristics that might influence the enrollment process.

Aims

What works, how and for whom, in increasing enrollment in studies in PC on patients with hematologic malignancies?

Methods

Realist review: a qualitative review whose goal is to identify and explain the interaction between Contexts, Mechanisms, and Outcomes (CMOs). The theory was informed by a narrative, theory-based literature research, including an initialsystematic research, and the addition of papers suggested by experts of the field. We also used 7 interviews with experts in PC about patients with hematologic malignancies research and our own experience from a PC pilot study on patients with hematologic malignancies to refine the initial theory.

Results

In our initial theory we hypothesize that:

 - Access to palliative care could be beneficial to hematologic patients, even in early stages

 - Hematologists tend to under-use palliative care services in general, due to unpredictable disease trajectories and cultural barriers.

 - These factors may negatively impact the patients’ enrollment in PC research

We included secondary literature as narrative reviews, if they presented interesting propositions useful for our theoretical construction. 23 papers met our inclusion criteria.

We also searched for relevant CMOs impacting referral in palliative care, and we selected a list of CMOs that could be relevant also in hematology. We accordingly theorized a group of interventions that could increase the enrollment in PC research and presented them using “social exchange theory” (SET) as a theoretical framework.

Prominent researchers in PC in hematologic malignancies were interviewed on their opinion on our results, and additional CMOs.

Conclusions

Before conducting research in PC on patients with hematologic malignancies, it’s probably advisable to assess:

 - The perception of the different actors (physicians, nurses, other professionals involved), in particular the hematologists, in terms of pros and cons of referral to PC and enrollment in PC trials

 - The existing relationship between PC and the Hematology department

Accordingly, it’s possible to tailor different interventions on the various actors and choose a model of trial to increase the perception of benefits from PC and, consequently, enrollment.

Coping Skills Interventions for Fatigue in Adults with Hematologic Malignancies: A Systematic Review

Background: Persons with hematologic malignancies have a high symptom burden throughout the illness journey. Coping skills interventions effectively reduce fatigue for other cancer patients. The purpose of this systematic review is to identify if coping interventions can reduce fatigue in patients with hematologic malignancies. Methods: A search of PubMed, Embase, CINAHL, APA Psych INFO, Scopus, Cochrane, and non-traditional publications was performed in June 2021 for studies introducing coping interventions for adults with hematological cancers within the past 20 years. The Transactional Model of Stress and Coping was used as a framework with fatigue as the primary outcome. The Johns Hopkins Nursing Evidence Based Practice Appraisal tool was used for quality appraisal. Results: Twelve interventional studies met criteria for inclusion. Four studies significantly reduced fatigue, with an additional 3 showing a reduction in fatigue. Interventions that utilized both problem and emotion-focused coping were more effective at reducing fatigue compared to interventions that only used emotion or problem-focused coping. Conclusion: This systematic review found moderate-strength evidence to support that coping interventions can reduce fatigue, with mixed, but mostly beneficial results. Clinicians caring for patients with hematologic malignancies should consider using coping interventions to reduce fatigue.

Timing of referral to outpatient palliative care for patients with haematologic malignancies

Outpatient palliative-care facilitates timely supportive-care access; however, there is a paucity of studies on the timing of referral in the outpatient setting for patients with haematologic malignancy. We examined the trend in timing of outpatient palliative-care referrals over a 10-year period in patients with haematologic malignancies at our comprehensive cancer centre. We included consecutive patients with a diagnosis of haematologic malignancy who were seen at our outpatient palliative-care clinic between 1 January 2010 and 31 December 2019. We collected data on patient characteristics, symptom burden and supportive-care interventions at outpatient palliative-care consultation. The primary outcome was time from outpatient palliative-care consultation to death or last follow-up. In all, 384 patients were referred by leukaemia (n = 143), lymphoma (n = 213), and stem cell transplant (n = 28) services. The median time from outpatient palliative-care referral to death was 3.4 years (IQR 2.4-5.3) with a significant increase in both the number of referrals per year (p = 0.047) and the timing of referral between 2010 and 2019 (p = 0.001). Patients with haematologic malignancies were referred in a timely fashion to our outpatient palliative-care clinic, with earlier and greater numbers of referrals over time.

Utility of Palliative Prognostic Index in Predicting Survival Outcomes in Patients With Hematological Malignancies in the Acute Ward Setting

BACKGROUND

The palliative prognostic index (PPI) predicts the life expectancy of patients with terminally ill cancer in hospice settings. This study aimed to evaluate PPI as a prognostic tool for predicting the life expectancy of patients with hematological malignancies admitted to the acute ward.

METHODS

A total of 308 patients with hematological malignancies admitted to the hematological ward at a medical center between January 2016 and December 2017 were consecutively enrolled. PPI was scored within 24 h of admission. All patients were categorized into 3 groups by PPI for comparing survival and in-hospital mortality rates.

RESULTS

The median survival times were 38.4, 3.6, and 1.1 months for patients with good, intermediate, and poor prognostic group, respectively. The hazard ratio was 2.31 (95% CI 1.59-3.35, p < 0.001) when comparing the intermediate and good prognosis groups, and 3.90 (95% CI 2.52-6.03, p < 0.001) when comparing the poor and good prognosis groups. Forty-five (14.6%) patients died at discharge; in-hospital mortality rates among the good, intermediate, and poor prognostic groups were 9.0%, 23.4%, and 46.4%, respectively. The adjusted odds ratio for in-hospital mortality was 1.96 (95% CI, 0.80-4.82, p = 0.14) and 5.25 (95% CI, 2.01-13.7, p < 0.001) for patients in the intermediate and poor prognostic groups compared to those in the good prognostic group.

CONCLUSION

PPI is an accurate prognostic tool for predicting survival times and in-hospital mortality rates in patients with hematological malignancies in an acute ward setting. PPI could assist clinicians in discussing end-of-life issues and in referring patients with hematological malignancies to palliative care.

Informal Caregiving for People With Life-Limiting Illness: Exploring the Knowledge Gaps

Background: People with life-limiting illness are increasingly having more care provided to them by informal caregivers (ICs) such as family members and friends. Although there is a substantial amount of literature surrounding informal caregiving, there is a paucity of research from a hospice palliative care angle. To address this knowledge gap, this scoping review explored the effects of/challenges to informal caregiving at the end of life in Canada. Methods: Scoping review of the literature following Arksey and O’Malley’s framework. Key healthcare and social sciences databases alongside the gray literature were searched. Relevant scholarly and gray literature sources from 2005 to 2019 were screened for inclusion criteria, and a thematic content analysis employed to summarize findings. Results: Of 2,717 initial search results, 257 distinct full text articles were obtained. Following deduplication and screening, 33 met inclusion criteria. Four major themes were identified: (1) Physical health challenges, (2) Psycho-socio-spiritual health challenges, (3) Financial issues, and (4) Health system issues. Gender of ICs was also found to be an important contributor to the differing effects of providing support. Conclusions: This review raises awareness toward ICs regarding the numerous physical, psycho-socio-spiritual, financial, and health system challenges faced during care for people with life-limiting illness. The knowledge gained will inform and advance future practice, policy, and research. Application to interventions (such as caregiver benefits) will assist to improve informal caregiving experiences and outcomes alongside quality of life. Further research is required to understand these unique experiences and the challenges of minority IC populations.