Haematology and palliative care: an account of shared care for a patient undergoing bone marrow transplantation for chronic myeloid leukaemia

End-of-life Care for Hematological Malignancies: The ‘Technological Imperative’ and Palliative Care

Recent research indicates that hospice/ palliative care practices have not yet been integrated into the care of patients with hematological malignancies. As research in relation to palliative care and hematological malignancies is in its infancy, many of the end-of-life care practices with these diagnostic groups are based on unexamined ideas. The findings presented in this article, which are taken from recent post-doctoral research on hematological malignancies and palliative care, make a contribution to documenting information on what is happening to patients and their families in this area. In particular, the findings provide insights on issues associated with the patient and carer awareness that the patient is dying, understanding of prognosis, and the desire to die at home. Such insights are placed in the context of descriptions of the patients’ experience with treatment during the terminal stage.

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.

End-of-life care in hematology: update from Australia

The purpose of this article is to provide recent findings on the perceptions and experiences about end-of-life care for individuals with a hematological malignancy. A qualitative design based on a series of open-ended interviews and one focus group was utilized to explore and document the experience of survivorship from the perspective of adult patients diagnosed with a hematological malignancy. Fifty participants (n = 26 male; n = 24 female) were interviewed representing the major hematological diagnostic groups: Multiple Myeloma, Lymphoma, and Leukemia. The interviews and focus group were recorded, transcribed verbatim, coded, and thematically analyzed. The findings presented are from the participants' experiences with end-of-life care. The findings indicated that those fortunate enough to know about the benefits of palliative care are more likely to access palliative care during end-of-life care. However, for many hematology patients there are still problems with timely referrals to the palliative system. Within the context of an Australian research program, the findings provide a useful "snapshot" of current issues for Australian hematology patients and their families.

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.

Palliative care in BMT

The field of high-dose therapy and SCT has made many advances in the past several years and the success rates have been steadily increasing as newer therapies emerge and improvements in supportive care continue to improve patient survival and cure rates. There still remains a mortality risk for high-dose therapy and the need for palliative care becomes more apparent as the focus also incorporates quality of life in all facets of cancer treatment and care. This paper reports on the lack of literature available on palliative care into the BMT and explores areas of future research in the integration of these two fields of medicine.

Description of an Australian model for end-of-life care in patients with hematologic malignancies

PURPOSE/OBJECTIVES

To present a model for end-of-life care in adult hematology that has been developed from nursing insights.

DATA SOURCES

Insights obtained from 25 nursing interviews during a two-year, qualitative, Australian National Health and Medical Research Council research study.

DATA SYNTHESIS

The nursing insights indicate that an understanding of end-of-life care in hematology needs to be set in a trilogy of overlapping models (labeled functional, evolving, and refractory) that address the complexity of issues associated with professional and hospital culture.

CONCLUSIONS

The authors have used the findings of their national research study to develop a useful, working model to assist with the integration of palliative care into adult hematology.

IMPLICATIONS FOR NURSING

The model develops a new language for understanding and fostering the integration of palliative care and hematology.

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

Recent hematology clinical guidelines recommend that palliative care specialists should have central roles in hemato-oncology teams. However, the available research evidence indicates there are presently significant obstacles to the integration of palliative care in hematology. The following discussion presents findings from an Australian study designed to address the problems associated with lack of referral of hematology patients to the palliative system through the development of a best-practice model for end-of-life care for these diagnostic groups. The preliminary step in the development of such a model is to document the factors that denote the special characteristics of the end-of-life stage of hematological conditions and their treatments. This article presents the list of special considerations from a nursing perspective, including issues associated with the high-tech nature of treatments, the speed of change to a terminal event, the need for blood products and possibility of catastrophic bleeds, the therapeutic optimism based on a myriad of treatment options and the clinical indices of the terminal trajectory. The nursing insights provide an important foundation for building a practical, patient-centred model for terminal care in hematology.

Missed opportunities: nursing insights on end-of-life care for haematology patients

There is now extensive consumer research to indicate that patients with haematological malignancies are not receiving appropriate or timely referrals to the palliative system. This paper begins to explore the issue from the professional perspective by presenting findings from haematology nurses on their experience with terminal care. The nursing insights have been gathered through open-ended interviews with a national sample of nurses with extensive experience in haematology in both public and private hospitals throughout Australia. The findings resonate with the previous consumer research in that all the acute care nurses affirmed that it is their belief, based on their professional experience, that patients from these diagnostic groups typically die in the acute ward dealing with escalating technology and invasive treatments. For some, the statements could be qualified by the satisfaction that they worked in a haematology unit, aware of the death-denying issues, trying to address the problem. Others, caught in a 'refractory' subculture (i.e. a subculture with a negative perception of palliative care), outlined the factors driving the lack of integration for their specific hospital. The focus of the discussion of findings is on the latter.

Are we making progress? Not in haematology!

It will be shown, through the presentation of recent research findings, that haematology is a neglected area in terms of sensitive care of the dying. The Australian evidence indicates that scant progress has been made in relation to even the most basic palliative care practices such as sensitive, honest information giving or appropriate referral to the palliative system. Rather, the data show that during terminal trajectory, patients from these diagnostic groups and their families remain trapped in processes within the high-tech, curative system that are not responsive to the needs of the dying.

Qualitative findings on the experience of end-of-life care for hematological malignancies

There is a loud silence in the literature on the issues related to palliative care for hematological malignancies. This article presents information that begins to address that silence. The limited research that is available indicates that, to date, patients with a hematological malignancy and their families received scant attention with regards to the provision of palliative care. The findings presented in this article demonstrates that families are enduring considerable hardship and are left with much emotional pain and many unresolved issues when such care is not offered. It is hoped that the findings presented in this article will be used for developing effective strategies to ensure that patients with hematological malignancies and their families, no less than any others, can be afforded the dignity and respect that the appropriate provision of palliative services ensures.

Caregivers' insights on the dying trajectory in hematology oncology

It is increasingly acknowledged in the research literature that palliative care is not offered to patients with a hematologic malignancy. The evidence indicates that patients are not dying at home or in the comfort of the hospice setting but are more likely to end up in the high-tech care of an intensive care unit. The holistic, compassionate care of the hospice/palliative care philosophy is not routinely made available to either these patients or the families who care for them. However, little is known about what the end-of-life experience is for such patients and their families and how they are managing to negotiate their dying experience in a system that is designed to cure not to palliate. In particular, there is a dearth of information on what happens to the caregivers during what is characteristically a prolonged and difficult period of sustained caring within the high-tech system. This discussion presents findings from recent research that is beginning to document the experience of the dying trajectory for patients from these diagnostic groups and their families. The hope and expectation from such research is that the information will make a contribution to building multidisciplinary plans of care for hematologic malignancies during the dying trajectory, to ensure that patients and their families are appropriately referred to the palliative system or, at least, are given sensitive palliative care within the curative system.