Special considerations for haematology patients in relation to end-of-life care: Australian findings

Resuscitation, yes or no ? the criteria for transferring patients with hematological malignancies to intensive care. A qualitative study

BACKGROUND

Having a hematological malignancy increases the risk of a poor-quality end of life and of dying in intensive care. There is no prognostic score to predict survival on admission to intensive care, but many patients die there. To identify the criteria used in deciding to transfer patients with hematological malignancies to intensive care.

METHODS

It is a qualitative study. For each patient with a hematological malignancy who died in intensive care, the resuscitator and hematologist involved in the decision to transfer the patient to intensive care were contacted. The study ran at Lyon Sud Hospital Center, between 1 November 2018 and 30 April 2019. Semi-structured interviews were conducted with data triangulation. Seventeen doctors were contacted, and 17 interviews were conducted.

RESULTS

When transferring a patient with a hematological malignancy to intensive care, we identified (i) patient-specific decision criteria for the transfer, namely prognosis of the disease and treatments received, and (ii) decision criteria specific to hematologists and resuscitators, namely difficulty confronting management failure, convenience of transfer to the ICU for hematologists, and attachment of hematologists to their patients.

CONCLUSION

Organizational convenience of transfer to intensive care was the main criterion for hematologists, but emotional attachment favored futile obstinacy, doing everything possible to the detriment of the patient's comfort. It would be useful to make an upstream appraisal of the impact that an early evaluation of the level of care of patients with hematological malignancies could have on reducing deaths in intensive care.

Decreased aggressive care at the end of life among advanced cancer patients in the Republic of Korea: a nationwide study from 2012 to 2018

BACKGROUND

This study aimed to investigate the trends of aggressive care at the end-of-life (EoL) for patients with advanced cancer in Korea and to identify factors affecting such care analyzing nationwide data between 2012 to 2018.

METHODS

This was a population-based, retrospective nationwide study. We used administrative data from the National Health Insurance Service and the Korea Central Cancer Registry to analyze 125,350 patients aged 20 years and above who died within one year of a stage IV cancer diagnosis between 2012 and 2018.

RESULTS

The overall aggressiveness of EoL care decreased between 2012 and 2018. In patients' last month of life, chemotherapy use (37.1% to 32.3%; p < 0.05), cardiopulmonary resuscitation (13.2% to 10.4%; p < 0.05), and intensive care unit admission (15.2% to 11.1%; p < 0.05) decreased during the study period, although no significant trend was noted in the number of emergency room visits. A steep increase was seen in inpatient hospice use in the last month of life (8.6% to 26.6%; p < 0.05), while downward trends were observed for hospice admission within three days prior to death (13.9% to 11%; p < 0.05). Patients were more likely to receive aggressive EoL care if they were younger, women, had treatment in tertiary hospitals, or had hematologic malignancies. In the subgroup analysis, the overall trend of aggressive EoL care decreased for all five major cancer types.

CONCLUSION

The aggressiveness of EoL care in stage IV cancer patients showed an overall decrease during 2012-2018 in Korea.

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.

Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021

Simple Summary

The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021.

Abstract

Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.

Haematological cancer versus solid tumour end-of-life care: a longitudinal data analysis

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.

A qualitative evidence synthesis of healthcare professionals' experiences and views of palliative care for patients with a haematological malignancy

INTRODUCTION

Patients with haematological malignancies may not be receiving appropriate referrals to palliative care and continuing to have treatments in the end stages of their disease. This systematic review of qualitative research aimed to synthesise healthcare professionals' (HCPs) views and experiences of palliative care for adult patients with a haematologic malignancy.

METHODS

A systematic search strategy was undertaken across eight databases. Thomas and Harden's approach to thematic analysis guided synthesis on the seventeen included studies. GRADE-GRADEQual guided assessment of confidence in the synthesised findings.

RESULTS

Three analytic themes were identified: (a) "Maybe we can pull another 'rabbit out of the hat'," represents doctors' therapeutic optimism, (b) "To tell or not to tell?" explores doctors' decision-making around introducing palliative care, and (c) "Hospice, home or hospital?" describes HCPs concerns about challenges faced by haematology patients at end of life in terms of transfusion support and risk of catastrophic bleeds.

CONCLUSION

Haematologists value the importance of integrated palliative care but prefer the term "supportive care." Early integration of supportive care alongside active curative treatment should be the model of choice in haematology settings in order to achieve the best outcomes and improved quality of life.

End-of-Life Trajectories of Patients With Hematological Malignancies and Patients With Advanced Solid Tumors Visiting the Emergency Department: The Need for a Proactive Integrated Care Approach

Purpose:

Patients with hematological malignancies (HM) have more unpredictable disease trajectories compared to patients with advanced solid tumors (STs) and miss opportunities for a palliative care approach. They often undergo intensive disease-directed treatments until the end of life with frequent emergency department (ED) visits and in-hospital deaths. Insight into end-of-life trajectories and quality of end-of-life care can support arranging appropriate care according to patients’ wishes.

Method:

Mortality follow-back study to compare of end-of-life trajectories of HM and ST patients who died <3 months after their ED visit. Five indicators based on Earle et al. for quality of end-of-life care were assessed: intensive anticancer treatment <3 months, ED visits <6 months, in-hospital death, death in the intensive care unit (ICU), and in-hospice death.

Results:

We included 78 HM patients and 420 ST patients, with a median age of 63 years; 35% had Eastern Cooperative Oncology Group performance status 3-4. At the ED, common symptoms were dyspnea (22%), pain (18%), and fever (11%). After ED visit, 91% of HM patients versus 76% of ST patients were hospitalized (P = .001). Median survival was 17 days (95% confidence interval [CI]: 15-19): 15 days in HM patients (95% CI: 10-20) versus 18 days in ST patients (95% CI: 15-21), P = .028. Compared to ST patients, HM patients more often died in hospital (68% vs 30%, P < .0001) and in the ICU or ED (30% vs 3%, P < .0001).

Conclusion:

Because end-of-life care is more aggressive in HM patients compared to ST patients, a proactive integrated care approach with early start of palliative care alongside curative care is warranted. Timely discussions with patients and family about advance care planning and end-of-life choices can avoid inappropriate care at the end of life.

Association between palliative care and end-of-Life care for patients with hematological malignancies: A population-based study

To date, few studies have examined the end-of-life (EOL) care for patients with hematological malignancies (HMs). We evaluated the effects of palliative care on the quality of EOL care and health care costs for adult patients with HMs in the final month of life.We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information for patient medical records, health care costs, and insurance system exit dates (our proxy for death) between 2000 and 2011.A total of 724 adult patients who died of HMs were investigated. Of these patients, 43 (5.9%) had received only inpatient palliative care (i-Pal group), and 19 (2.6%) received home palliative care (h-Pal group). The mean health care costs during the final month of life were not significantly different between the non-Pal and Pal groups (p=0.315) and between the non-Pal, i-Pal, and h-Pal groups (p=0.293) either. By the multivariate regression model, the i-Pal group had lower risks of chemotherapy, ICU admission, and receipt of CPR, but higher risks of at least two hospitalizations and dying in hospital after adjustments. The h-Pal group had the similar trends as the i-Pal group but lower risk of dying in hospital after adjustments.Patients with HMs who had received palliative care could benefit from less aggressive EOL cancer care in the final month of life. However, 8.6% patients with HMs received palliative care. The related factors of more hospitalizations and dying in hospital warrant further investigation.

Access to palliative care for cancer patients between diagnosis and death: a national cohort study

Background and purpose: Introducing palliative care earlier in the disease trajectory has been found to provide better management of physical and psychological suffering. In France, the proportion of cancer patients who receive palliative care is unclear. This study aimed primarily to measure the prevalence of access to inpatient palliative care and associated patient-level factors, and to identify the time between access to palliative care and death. Patients and methods: A nationwide retrospective cohort study using data from the French national health system database (SNDS). All those diagnosed with cancer in 2013 who died between 2013 and 2015 were included. Access to inpatient palliative care was the main outcome. Results: Of the 313,059 patients diagnosed with cancer in 2013 in France, 72,315 (23%) died between 2013 and 2015. Overall, 57% had access to inpatient palliative care. The following groups were the most likely to have access to palliative care: women (adjusted odds ratio, aOR: 1.15; 95% CI: 1.11-1.20), people aged 18-49 (aOR: 1.38; 95% CI: 1.26-1.51), individuals with metastatic cancer (aOR: 2.04; 95% CI: 1.96-2.13), and patients with cancer of the nervous system (aOR: 1.80; 95% CI: 1.62-2.01). The median time between palliative care and death was 29 (interquartile range: 13-67) days. Conclusion: More than half of cancer patients who died within 2 years after diagnosis had access to inpatient palliative care. Access to palliative care occurs late in the disease trajectory, often during the final month of life. Further research and guidelines are warranted to optimize access to early, standardized palliative care.

Perspectives of bereaved relatives of patients with haematological malignancies concerning preferred place of care and death: A qualitative study

BACKGROUND

People with haematological malignancies have different end-of-life care patterns from those with other cancers and are more likely to die in hospital. Little is known about patient and relative preferences at this time and whether these are achieved.

AIM

To explore the experiences and reflections of bereaved relatives of patients with leukaemia, lymphoma or myeloma, and examine (1) preferred place of care and death; (2) perceptions of factors influencing attainment of preferences; and (3) changes that could promote achievement of preferences.

DESIGN

Qualitative interview study incorporating 'Framework' analysis.

SETTING/PARTICIPANTS

A total of 10 in-depth interviews with bereaved relatives.

RESULTS

Although most people expressed a preference for home death, not all attained this. The influencing factors include disease characteristics (potential for sudden deterioration and death), the occurrence and timing of discussions (treatment cessation, prognosis, place of care/death), family networks (willingness/ability of relatives to provide care, knowledge about services, confidence to advocate) and resource availability (clinical care, hospice beds/policies). Preferences were described as changing over time and some family members retrospectively came to consider hospital as the 'right' place for the patient to have died. Others shared strong preferences with patients for home death and acted to ensure this was achieved. No patients died in a hospice, and relatives identified barriers to death in this setting.

CONCLUSION

Preferences were not always achieved due to a series of complex, interrelated factors, some amenable to change and others less so. Death in hospital may be preferred and appropriate, or considered the best option in hindsight.

Symptoms and anxiety predict declining health-related quality of life in multiple myeloma: A prospective, multi-centre longitudinal study

BACKGROUND

Patients with multiple myeloma, an incurable haematological cancer, often receive palliative care only late in their trajectory. Criteria for early referral are lacking.

AIM

To identify which patients might benefit from early integration, by identifying trajectories of health-related quality of life and the determinants for declining or poor Health related quality of life .

DESIGN

Prospective, longitudinal cohort study.

PARTICIPANTS

Multiple myeloma patients at all stages (newly diagnosed, first-line or second-line treatment, early or later treatment-free interval, refractory disease) from in- and outpatient units at 14 hospitals in England were recruited. In addition to clinical information and standardised Health related quality of life and psychological aspects, the Myeloma Patient Outcome Scale (MyPOS) measured palliative care concerns.

RESULTS

A total of 238 patients were recruited, on average 3.5 years ( SD: 3.4) post-diagnosis. Latent mixture growth models identified four Health related quality of life trajectories. Classes 3 and 4 represent trajectories of stable poor Health related quality of life or declining Health related quality of life over an 8-month period. The strongest predictors of poor outcome at the end of follow-up were general symptom level (odds ratio (OR): 1.3, 95% CI: 1.0-1.6, p = 0.028), presence of clinically relevant anxiety (OR: 1.2, 95% confidence interval (CI): 1.0-1.4, p = 0.019), and presence of pain (OR: 1.02, 95% CI: 1.0-1.1, p = 0.018), all being more predictive than demographic or clinical characteristics.

CONCLUSION

General symptom level, pain and presence of anxiety predict declining Health related quality of life in multiple myeloma. Identification of patients with palliative care needs should focus on assessing patient-reported symptoms and psychosocial well-being for identifying those at risk of deterioration.

Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study

PURPOSE

Patients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients' places of care and death.

METHOD

Qualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach.

RESULTS

Five inter-related factors were identified as contributing to the likelihood of patients' receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home.

CONCLUSIONS

Hospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.

Patterns of end-of-life hospital care for patients with non-Hodgkin lymphoma: exploring the landscape

Rapid change, treatment responsiveness, and prognostication difficulties present challenges for palliative care integration for hematology patients. This Australian study aimed to document end-of-life hospital care for patients with non-Hodgkin lymphoma (NHL) to consider opportunities for palliative care integration. A retrospective population cohort design examining existing linked datasets of health service utilization and death registration. The results revealed 4380 NHL patients, majority male (58%) and aged 70+ years (70%), spent 32 days (median) in hospital in final 6 months of life, and in the last month, 56% had more than 1 hospital admission, and 57% stayed more than 14 days. Forty-one percent accessed palliative care, with first contact 23 days (median) before death, and for 77% in final admission. Early palliative care was more likely for patients with greater symptom burden. This study mapping patterns of care for patients who die from NHL establishes a baseline enabling comparisons for future care innovations.

Use and timing of referral to specialized palliative care services for people with cancer: A mortality follow-back study among treating physicians in Belgium

Background

Referral to specialized palliative care services (SPCS) occurs often late in the illness trajectory but may differ across cancer types. We examined differences between cancer types in the use and timing of referral to specialized palliative care services (SPCS) and in the reasons for non-referral.

Methods

We conducted a population-based mortality follow-back survey among physicians who certified a representative sample of deaths in Flanders, Belgium. We focused only on sampled death cases of cancer (n = 2392). The questionnaire asked about the use of the existing types of SPCS and the timing of referral to these services.

Results

Response rate was 58% (1394/2392). Patients who died from breast, respiratory, head and neck, genitourinary or gastrointestinal cancer had higher chances of using SPCS compared to hematologic cancer patients. The most prevalent reason for non-referral was that regular care sufficiently addressed palliative and supportive care needs (51%). This differed significantly between cancer types ranging from 77,8% for breast cancer and 42.1% for hematologic cancer. A second prevalent reason for not using SPCS was that it was not meaningful (enough) (23.9%), particularly for hematologic malignancies (35,1%) and only in 5.3% for breast cancer.

Conclusion

Differences in referral across different types of cancer were found. Referral is more often delayed or not initiated for patients with hematologic cancer, possibly due to differences in illness trajectory. An influencing reason is that physicians perceive palliative care as not meaningful or not meaningful enough for these patients which may be linked to the uncertainty in the disease trajectory of hematologic malignancies.

Clinical Indicators That Identify Risk of Deteriorating and Dying in People with a Hematological Malignancy: A Case-Control Study with Multivariable Analysis

BACKGROUND

Identifying people who are at risk of deteriorating and dying is essential to inform goals of care, appropriate treatment decisions, patient autonomy, and effective end-of-life care. Limited literature exists on predicting survival near the end of life for people with a hematological malignancy.

OBJECTIVE

To identify the key clinical indicators that signal a person with a hematological malignancy is at high risk of deteriorating and dying.

DESIGN, SETTING, PARTICIPANTS

Eleven clinical indicators identified in a Delphi approach were tested via a retrospective case-control study. Each indicator was assessed for at each in-patient admission between living (n = 236) and deceased (n = 120) people with a hematological malignancy who were admitted to a large tertiary hospital between 1st July 2014 and 31st December 2015.

RESULTS

Six clinical indicators were independently associated with mortality in the final three months of life: declining performance status (Odds Ratio [OR] 7.153, 95% Confidence Intervals [CI] 3.281-15.597, p = < 0.001); treatment limitations of the hematological malignancy (OR 7.855, 95% CI 3.528-17.489, p = < 0.001); relapse, refractory or persistent disease (OR 3.749, 95% CI 1.749-8.039, p = 0.001); presence of two or more comorbidities (OR 2.991, 95% CI 1.319-6.781, p = 0.009); invasive fungal infections (OR 4.887, 95% CI 1.197-19.949, p = 0.027); and persistent infections (OR 6.072, 95% CI 2.551-14.457, p = < 0.001).

CONCLUSIONS

This study has identified six clinical indicators that signal a person with a hematological malignancy is at high risk of deteriorating and dying and may benefit from an assessment of palliative needs and proactive planning, along-side appropriate treatment.

Reflection on curative treatment versus palliation of symptoms in end of life care

The conflicting tasks of treating or managing disease and preparing patients and their families for the end of life are well documented in haematology and palliative care settings. This article is a reflection on practice by a nursing student who was in the fourth year of an internship, and discusses a case study involving a woman at the end of life. It considers the approach to palliative and end of life care adopted in an oncology and haematology ward where there was a reluctance to be realistic about the limitations of treatments among some healthcare practitioners, who did not want to dispel unrealistic expectations of the patient's recovery as a result of continuing treatment. This reflection focuses on the care of a patient at the end of life and the frustration experienced by the nursing student at their inability to alter the direction of treatment from curative treatment to the palliation of symptoms.

Palliative care in patients with haematological neoplasms: An integrative systematic review

BACKGROUND

Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies.

AIM

To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments.

DESIGN

Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240).

DATA SOURCES

PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies.

RESULTS

The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking.

CONCLUSION

Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.

Signs, Symptoms, and Characteristics Associated With End of Life in People With a Hematologic Malignancy: A Review of the Literature

PROBLEM IDENTIFICATION

Identifying people with hematologic cancer who are at risk of deteriorating and dying is essential to enable open, honest discussions, leading to appropriate decision making and effective end-of-life care.
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LITERATURE SEARCH

PubMed, CINAHL®, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 2005 to December 2015 for descriptive observational studies.
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DATA EVALUATION

Critique of the studies was guided by the Critical Appraisal Skills Programme Cohort Study Checklist.
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SYNTHESIS

Twelve studies were included. The majority of studies (n = 8) sampled patients from palliative populations, and most were retrospective (n = 11). A number of signs, symptoms, and characteristics associated with end of life in people with a hematolgic malignancy were identified, including pain, hematopoietic dysfunction, dyspnea, and reduced oral intake.
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CONCLUSIONS

The studies described a clinical scenario of deterioration, largely in a palliative population. Findings indicate that people with a hematologic malignancy share certain clinical signs of deterioration with other populations and receive a high level of medical interventions at the end of life.
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IMPLICATIONS FOR PRACTICE

Nurses are well positioned to identify many of the signs, symptoms, and characteristics found in this review and can play a key role in identifying when a person is nearing the end of life.

Improving the Transition to Palliative Care for Patients With Acute Leukemia: A Coordinated Care Approach

BACKGROUND

Currently, there is little guidance available for documenting and executing the change in management goals in the context of incurable hematologic disease.

OBJECTIVE

The aim of this study was to improve the transition to palliative care for patients with acute myeloid leukemia (AML) through the development and implementation of a coordinated care plan program.

METHODS

Twenty-three patients with AML who were no longer being treated with curative intent from March 2011 through September 2012 had hematology supportive care plans developed. Patients (n = 7) completed post-care plan implementation questionnaires to determine their level of understanding in relation to the change in treatment intent. Staff completed pre- (n = 26) and post- (n = 19) care plan implementation questionnaires to determine the communication, challenges, and accessibility of changed management goals.

RESULTS

Seventy-seven percent of patients understood palliative care to be the primary team managing their symptoms, with 75% of patients viewing symptom control as the main goal of treatment. Staff findings demonstrated a significant improvement in the communication of treatment goals (53% preimplementation vs 86% postimplementation). Early timing of referrals remains a significant issue.

CONCLUSIONS

Implementing the individualized care plan program was associated with better communication and accessibility of documented palliative treatment goals for patients with AML.

IMPLICATIONS FOR PRACTICE

This study establishes a model of care that addresses symptom and disease burden in end-stage AML and provides valuable insight into the patient and family understanding of treatment intent during this terminal phase.

A systematic review of prognostic factors at the end of life for people with a hematological malignancy

Background

Accurate prognosticating is needed when patients are nearing the end of life to ensure appropriate treatment decisions, and facilitate palliative care provision and transitioning to terminal care. People with a hematological malignancy characteristically experience a fluctuating illness trajectory leading to difficulties with prognosticating. The aim of this review was to identify current knowledge regarding ‘bedside’ prognostic factors in the final 3 months of life for people with a hematological malignancy associated with increased risk of mortality.

Methods

A systematic review of the literature was performed across: PubMed; CINAHL; PsycINFO; and Cochrane with set inclusion criteria: 1) prognostic cohort studies; 2) published 2004–2014; 3) sample ≥ 18 years; 4) >50% sample had a hematological malignancy; 5) reported ‘bedside’ prognostic factors; 6) median survival of <3 months; and 7) English language. Quality appraisal was performed using the Quality In Prognostic Studies (QUIPS) tool. Results are reported in line with PRISMA guidelines.

Results

The search returned 4860 studies of which 28 met inclusion criteria. Twenty-four studies were rated moderate quality, three were high quality and one study was deemed to be of low quality. Most studies were set in the ICU (n = 24/28) and were retrospective (n = 25/28). Forty ‘bedside’ prognostic factors were identified as associated with increased risk of mortality encompassing the following broad categories: 1) demographics; 2) physiological complications or conditions; 3) disease characteristics; 4) laboratory blood values; and 5) interventions.

Conclusions

The literature on prognosticating in the final months of life was predominantly focused on people who had experienced acute physiological deterioration and were being treated aggressively in the in-patient setting. A significant gap in the literature exists for people who are treated less aggressively or are on a palliative trajectory. Findings did not report on, or confirm the significance of, many of the key prognostic factors associated with increased risk of mortality at the end of life in the solid tumour population, demonstrating key differences in the two populations.

Trial registration

This systematic review was not registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3207-7) contains supplementary material, which is available to authorized users.

Barriers to the Collaboration Between Hematologists and Palliative Care Teams on Relapse or Refractory Leukemia and Malignant Lymphoma Patients’ Care

Background:

Palliative care service (PCS) has been shown to be utilized less in patients with leukemia and malignant lymphoma than in those with solid tumors. Previous studies have suggested hematologists’ limited awareness of PCS as one of the reason for low PCS referral in hematology. However, little is known about such an awareness and potential barriers to collaboration between hematologists and PCS.

Aim:

The present study aimed to assess ematologists and palliative care specialists’ perception about the roles of the hospital-based palliative care team (HPCT) and the barriers to collaboration between hematologists and palliative care teams on relapse or refractory leukemia and malignant lymphoma patients’ care

Materials and Methods:

A qualitative study was conducted using semistructured interviews with hematologists and palliative care specialists recruited from a hospital that provides hematology and palliative care by the HPCT. Data were evaluated via content analysis.

Results:

The study included 11 hematologists and 10 palliative care specialists. Our results revealed that they shared many common perceptions about the roles and expectations of the HPCT. Additionally, 7 categories of barriers to collaboration were identified, including not feeling the need to refer, the difficulty in referral timing, the lack of aggressive approach, the negative image of the HPCT, the need for hematologic malignancy-oriented management, the lack of communication, and others.

Conclusion:

We have identified hematologists’ and palliative care specialists’ perceptions of the HPCT’s roles and the barriers to their collaboration. A better understanding of such barriers may lead to effective collaboration between hematologists and the HPCT.

Validation of 2 Prognostic Models in Hospitalized Patients With Advanced Hematological Malignancies in Japan

Patients with advanced hematological malignancies are less likely to be referred to specialist palliative care services compared with patients having solid tumors. It has been reported that one of the most important reasons for the lack of referral is difficulties in the prognostication of terminally ill patients with hematologic malignancies. The study objective was to evaluate the predictive accuracy of the Palliative Prognostic Index (PPI) and the prognostic model developed by Kripp et al in hospitalized patients under the care of a hematologist. Using clinical charts, we retrospectively calculated the above scores. We reviewed the records of 114 patients admitted to the hematology ward. The inclusion criterion was patient with disease considered incurable using standard treatments. The prognostic models were assessed according to the original reports. Using PPI cutoff points of 2 and 4, we divided the patients into 3 groups of significantly different survival times ( P < .01). Moreover, we confirmed the usefulness of predicting survival <3 and <6 weeks using PPI scores of 6 and 4 as cutoff points, respectively. When we classified patients according to the prognostic model of Kripp et al, the high-risk group survived significantly shorter times than the intermediate- and low-risk groups ( P < .001). However, there was no significant difference in survival between the intermediate- and low-risk groups. Use of these models might enable physicians to provide more appropriate end-of-life care and to refer patients to palliative care earlier.

Is shared decision-making vanishing at the end-of-life? A descriptive and qualitative study of advanced cancer patients' involvement in specific therapies decision-making

Background

Little is known about what is at stake at a subjective level for the oncologists and the advanced cancer patients when they face the question whether to continue, limit or stop specific therapies. We studied (1) the frequency of such questioning, and (2) subjective determinants of the decision-making process from the physicians’ and the patients’ perspectives.

Methods

(1) All hospitalized patients were screened during 1 week in oncology and/or hematology units of five institutions. We included those with advanced cancer for whom a questioning about the pursuit, the limitation or the withholding of specific therapies (QST) was raised. (2) Qualitative design was based on in-depth interviews.

Results

In conventional units, 12.8 % of cancer patients (26 out of 202) were concerned by a QST during the study period. Interviews were conducted with all physicians and 21 advanced cancer patients. The timing of this questioning occurred most frequently as physicians estimated life expectancy between 15 days and 3 months. Faced with the most frequent dilemma (uncertain risk-benefit balance), physicians showed different ways of involving patients. The first two were called the “no choice” models: 1) trying to resolve the dilemma via a technical answer or a “wait-and-see” posture, instead of involving the patients in the questioning and the thinking; and 2), giving a “last minute” choice to the patients, leaving to them the responsibility of the decision. In a third model, they engaged early in shared reflections and dialogue about uncertainties and limits with patients, proxies and care teams. These schematic trends influenced patients’ attitudes towards uncertainty and limits, as they were influenced by these ones. Individual and systemic barriers to a shared questioning were pointed out by physicians and patients.

Conclusions

This study indicate to what extent these difficult decisions are related to physicians’ and patients’ respective and mutually influenced abilities to deal with and share about uncertainties and limits, throughout the disease trajectory. These insights may help physicians, patients and policy makers to enrich their understanding of underestimated and sensitive key issues of the decision-making process.

Preferred and actual place of death in haematological malignancy

Objectives

Home is considered the preferred place of death for many, but patients with haematological malignancies (leukaemias, lymphomas and myeloma) die in hospital more often than those with other cancers and the reasons for this are not wholly understood. We examined preferred and actual place of death among people with these diseases.

Methods

The study is embedded within an established population-based cohort of patients with haematological malignancies. All patients diagnosed at two of the largest hospitals in the study area between May 2005 and April 2008 with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma, who died before May 2010 were included. Data were obtained from medical records and routine linkage to national death records.

Results

323 deceased patients were included. A total of 142 (44%) had discussed their preferred place of death; 45.8% wanted to die at home, 28.2% in hospital, 16.9% in a hospice, 5.6% in a nursing home and 3.5% were undecided; 63.4% of these died in their preferred place. Compared to patients with evidence of a discussion, those without were twice as likely to have died within a month of diagnosis (14.8% vs 29.8%). Overall, 240 patients died in hospital; those without a discussion were significantly more likely to die in hospital than those who had (p≤0.0001). Of those dying in hospital, 90% and 75.8% received haematology clinical input in the 30 and 7 days before death, respectively, and 40.8% died in haematology areas.

Conclusions

Many patients discussed their preferred place of death, but a substantial proportion did not and hospital deaths were common in this latter group. There is scope to improve practice, particularly among those dying soon after diagnosis. We found evidence that some people opted to die in hospital; the extent to which this compares with other cancers is of interest.

Hospice admissions for cancer in the final days of life: independent predictors and implications for quality measures

PURPOSE

To define patient characteristics associated with hospice enrollment in the last 3 days of life, and to describe adjusted proportions of patients with late referrals among patient subgroups that could be considered patient-mix adjustment variables for this quality measure.

METHODS

Electronic health record-based retrospective cohort study of patients with cancer admitted to 12 hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network.

RESULTS

Of 64,264 patients admitted to hospice with cancer, 10,460 (16.3%) had a length of stay ≤ 3 days. There was significant variation among hospices (range, 11.4% to 24.5%). In multivariable analysis, among patients referred to hospice, patients who were admitted in the last 3 days of life were more likely to have a hematologic malignancy, were more likely to be male and married, and were younger (age < 65 years). Patients with Medicaid or self-insurance were less likely to be admitted to hospice within 3 days of death.

CONCLUSION

Quality measures of hospice lengths of stay should include patient-mix adjustments for type of cancer and site of care. Patients with hematologic malignancies are at especially increased risk for late admission to hospice.

End-of-life characteristics and palliative care provision for elderly patients suffering from acute myeloid leukemia

PURPOSE

End-of-life care characteristics and palliative care (PC) utilization of elderly acute myeloid leukemia (AML) patients have rarely been reported. The aim of this study was to evaluate the cause of death, place of death and PC utilization of older adults (age 60 years or above) suffering from AML.

METHODS

Patients were recruited retrospectively from two hematology units in Hong Kong, which consisted of one university department with Bone Marrow Transplant service, and one regional hospital with hematology specialty service. Collaboration with PC unit was established. Elderly AML patients referred to PC service were included. Medical records of all identified patients would be reviewed retrospectively by two PC physicians.

RESULTS

From October 2011 to April 2013, 156 hematological cancer patients were referred for PC; 43 elderly AML patients were included into data analysis. The median time from AML diagnosis to death was 9.1 months. Up to 46.5% patients received supportive care alone since diagnosis. More than half of elderly AML patients died in acute ward and hematology units (53.5 %), while 30.2 % died in PC settings. Overall, 51.2% of patients spent the whole period of their final month of life in-hospital. Infection-related diagnoses contributed to 51.2% of deaths. Median time from AML diagnosis to first PC consultation was 1.0 month. PC service includes psychosocial support (100%), hospice in-patient care (30.2%), homecare (60.5%), PC outpatient clinic (14.0%) and bereavement care (93.0%).

CONCLUSIONS

Elderly AML patients carry dismal prognosis with their final phase of disease mostly hospitalized in acute care settings. Infections and bleeding could complicate course of illness and lead to rapid deterioration. PC collaboration remains important in psychosocial support and coverage of dying AML patients in non-hospice settings.

Quality of end-of-life care in patients with hematologic malignancies: a retrospective cohort study

BACKGROUND

To the authors' knowledge, only limited data are available regarding the quality of end-of-life care for patients with hematologic malignancies. In this retrospective cohort study, the quality of end-of-life care was compared between patients with hematologic malignancies and those with solid tumors.

METHODS

All adult patients who died of advanced cancer between September 1, 2009 and February 28, 2010 while under the care of the study institution were included. The authors collected baseline demographics and end-of-life care indicators, including emergency room visits, hospitalization, intensive care unit admissions, and systemic cancer therapy use within the last 30 days of life.

RESULTS

Of a total of 816 decedents, 113 (14%) had hematologic malignancies. In the last 30 days of life, patients with hematologic malignancies were more likely to have emergency room visits (54% vs 43%; P = .03), hospital admissions (81% vs 47%; P < .001), ≥ 2 hospital admissions (23% vs 10%; P < .001), > 14 days of hospitalization (38% vs 8%; P < .001), intensive care unit admissions (39% vs 8%; P < .001) and death (33% vs 4%; P < .001), chemotherapy use (43% vs 14%; P < .001), and targeted therapy use (34% vs 11%; P < .001) compared with patients with solid tumors. Patients with hematologic malignancies were also less likely to have palliative care unit admissions (8% vs 17%; P = .02). The composite score for aggressiveness of care (with 0 indicating the best and 6 indicating the worst) was significantly higher among patients with hematologic malignancies compared with those with solid tumors (median, 2 vs 0; P < .001). On multivariate analysis, hematologic malignancy was found to be a significant factor associated with aggressive end-of-life care (odds ratio, 6.6; 95% confidence interval, 4.1-10.7 [P < .001]).

CONCLUSIONS

The results of the current study indicate that patients with hematologic malignancies received more aggressive care at the end of life.

Intensive palliative care for patients with hematological cancer dying in hospice: analysis of the level of medical care in the final week of life

Dying of hematological oncology patients often take place in respective hematology ward or intensive care unit rather than hospice. With the increased attention to quality palliative care for hematology patients, concerns regarding their level of medical care at end-of-life need to be addressed. We conducted a retrospective review of consecutive hematological oncology patients who succumbed in a palliative unit between July 2012 and August 2013. The primary outcome measure was their level of medical care received, including administration of antibiotics, total parenteral nutrition, blood sampling, GCSF injection and blood products transfusion, during their last seven days of life. During the last seven days of life, 85.7 % of patients had blood sampling and 23.8% of patients received G-CSF injection. Total parenteral nutrition was administered in 14.3% of patients. One-third of patients received transfusion of packed cells and nearly half of them received transfusion of platelet concentrates. Almost 90% of patients received antibiotics during their last week of life. Collaboration between hematology and palliative care has resulted in successful transition of hematologic cancer patients into hospice unit in their terminal phase of illness. However, their level of medical care, even approaching last seven days of life, remained intensive. Proper allocation of medical resources and future research regarding optimal end-of-life care for hematology patients are warranted.

The importance of quality of life for patients living with myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are a group of myeloid stem cell clonal disorders characterized by a wide variation in illness trajectory and potential treatment. The physical, functional, emotional, social, and spiritual well-being of individuals with MDS can be affected by both disease and treatment-related factors. As a result, the quality of life (QOL) in patients with MDS may vary throughout the course of the illness. To date, most research exploring QOL in patients with MDS has been conducted as part of clinical trials evaluating the effectiveness of a therapeutic intervention. Although data from those studies are useful, they do not fully address the issues critical to maintaining or maximizing QOL. Oncology nurses are in a key position to assist patients with MDS to maintain their QOL. Findings from comprehensive QOL assessments will guide nurses in providing relevant interventions and evaluating their outcomes. In this manner, oncology nurses can assist their patients to maximize QOL while living with this challenging illness.

Meaning in bone marrow transplant nurses' work: experiences before and after a "meaning-centered" intervention

BACKGROUND

When a clinical culture emphasizes cure, as in bone marrow transplantation (BMT) services, BMT nurses commonly experience enormous stress when patients are suffering or dying. In this context, it is unclear what meanings BMT nurses experience in their work and how they find meaning and sustain hope, given conflicting responsibilities to patients.

OBJECTIVE

This study aimed to explore BMT nurses' experiences of meaning and hope and the effects of a meaning-centered intervention (MCI) on these experiences using qualitative methodology.

METHODS

Fourteen BMT nurses engaged in a 5-session MCI, with 7 members each participating in 2 groups. Semistructured qualitative interviews were conducted at 1 month before and after the intervention. Interpretive phenomenology guided data analysis.

RESULTS

The BMT nurses in the Princess Margaret Hospital experienced meaning in their involvement with their patients' suffering. The MCI seemed to inspire participants to engage more with patients and their suffering. Three subthemes reflected this influence: (a) greater awareness of boundaries between their personal and professional involvement, (b) enhanced empathy from an awareness of a shared mortality, and (c) elevated hope when nurses linked patients' suffering with meaning.

CONCLUSIONS

This study confirms that patients' suffering constitutes nurses' search for meaning and hope in their work. The MCI offers a way in which to actively support nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses can learn to be more responsive to patients' suffering beyond limits of cure. A minimal intervention, such as the MCI, supports BMT nurses in finding positive personal meaning and purpose in their otherwise highly stressful work culture.

Acute leukaemia: making sense of a complex blood cancer

Acute leukaemia represents a diverse group of blood cancers that affect both children and adults. Treatment schedules for these haematology cancers are often prolonged, with many associated side effects and complications. Nurses caring for patients with acute leukaemia require an anticipatory approach, where care is aimed at minimizing the side effects of treatment and being constantly vigilant for any impending adverse effects. Moreover, patients require support for the psychosocial issues that can arise for patients during their illness. This article provides an overview of acute lymphoblastic leukaemia and acute myeloid leukaemia. Nursing considerations in the care of patients being treated for acute leukaemia are also explored.

How haematological cancer nurses experience the threat of patients' mortality

AIM

This article explores how cancer nurses experienced the threat of patients' mortality on malignant haematology units of one institution in Ontario, Canada.

BACKGROUND

Although patients with cancer are living longer with bone marrow transplantations, still they face possibilities of dying due to complications from treatment and their disease.

METHODS

Interpretive phenomenology guided the process. Nineteen front-line registered nurses were purposively recruited from two inpatient bone marrow transplant units. Focused observations and individual interviews were analysed. Data were collected from April to August 2007.

RESULTS

The major findings emphasized nurses' internal conflict related to their simultaneous need to help patients fight their disease and to prepare them for the possibility of letting go. The authors used the terms 'letting go', not to reflect nurses' intents to abandon life but to release patients from perceived norms of the 'curative culture'. Nurses experienced 'bursting the bubble of hope' by circumstances not in their control, and were often not certain whether or not to respond and how to respond to the distress of patients and families about death and dying. When feeling reassured of meeting patients' and families' expectations, nurses enabled patients and families to let go when further treatment was futile, prevented technological intrusions, and helped patients have 'easier' deaths.

CONCLUSION

Results suggest enhancing nurses' capacity to negotiate more effectively the contradictory clinical tasks of fighting disease and preparing patients for the end of life. In this regard, nurses may minimize patients' distress by providing opportunities for them to share their fears and have them validated.

Haematological malignancy: are patients appropriately referred for specialist palliative and hospice care? A systematic review and meta-analysis of published data

Haematological malignancies are complex diseases, affecting the entire age spectrum, and having marked differences in presentation, treatment, progression and outcome. Patients have a significant symptom burden and despite treatment improvements for some sub-types, many patients die from their disease. We carried out a systematic review and meta-analysis to examine the proportion of patients with haematological malignancies that received any form of specialist palliative or hospice care. Twenty-four studies were identified, nine of which were suitable for inclusion in the meta-analysis. Our review showed that patients with haematological malignancies were far less likely to receive care from specialist palliative or hospice services compared to other cancers (Risk Ratio 0.46, [95% confidence intervals 0.42-0.50]). There are several possible explanations for this finding, including: ongoing management by the haematology team and consequent strong bonds between staff and patients; uncertain transitions to a palliative approach to care; and sudden transitions, leaving little time for palliative input. Further research is needed to explore: transitions to palliative care; potential unmet patient needs; where patients want to be cared for and die; existing practices in the delivery of palliative and end-of-life care; and barriers to specialist palliative care and hospice referral and how these might be overcome.

Destined to die in hospital? Systematic review and meta-analysis of place of death in haematological malignancy

Background

Haematological malignancies are a common, heterogeneous and complex group of diseases that are often associated with poor outcomes despite intensive treatment. Research surrounding end-of-life issues, and particularly place of death, is therefore of paramount importance, yet place of death has not been formally reviewed in these patients.

Methods

A systematic literature review and meta-analysis was undertaken using PubMed to identify all studies published between 1966 and 2010. Studies examining place of death in adult haematology patients, using routinely compiled morbidity and mortality data and providing results specific to this disease were included. 21 studies were identified with descriptive and/or risk-estimate data; 17 were included in a meta-analysis.

Results

Compared to other cancer deaths, haematology patients were more than twice as likely to die in hospital (Odds Ratio 2.25 [95% Confidence Intervals, 2.07-2.44]).

Conclusion

Home is generally considered the preferred place of death but haematology patients usually die in hospital. This has implications for patients who may not be dying where they wish, and also health commissioners who may be funding costly end-of-life care in inappropriate acute hospital settings. More research is needed about preferred place of care for haematology patients, reasons for hospital deaths, and how these can be avoided if home death is preferred.

What determines referral of UK patients with haematological malignancies to palliative care services? An exploratory study using hospital records

We investigated the frequency and characteristics of patients with haematological malignancies (HMs) who were, or were not, referred for specialist palliative care (SPC). Data were abstracted from hospital records of 108 patients who died - 27 with leukaemia, 11 with myelodysplastic syndromes, 48 with lymphoma and 22 with myeloma. Ninety-three patients (86.1%) were >60 years of age at diagnosis, with 33 (30.6%) being >or=80 years and 31 (28.7%) having existing comorbidities. Thirty-three patients (30.6%) were referred to SPC services. There was little difference by age or HM diagnosis in referred patients. Seventeen of 67 patients (25.4%) dying on a hospital ward received SPC compared with 6/7 (85.7%) dying at home. Time between diagnosis and death influenced the referral - 24/52 patients (46.2%) dying >or=30 days after diagnosis received SPC compared with 8/42 (19.1%) dying within 30 days. In 14 patients, HM diagnosis was confirmed after death. Identification of these 14 patients is likely to be a unique feature of our study, as patients were selected from a regional, population-based register with centralized diagnostic services, enabling the identification of all patients with HM. The interface between curative and palliative treatment in HM is more complex than the National Institute for Clinical Excellence recommendations suggest.