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

Palliative Care in Hematology: A Systematic Review of the Components, Effectiveness, and Implementation

CONTEXT

While the evidence supporting the benefits of integration of palliative care into cancer care for patients and informal caregivers is growing, it poses challenges for hematological cancer patients due to rapidly changing disease trajectories, uncertain prognosis, and diverse care needs.

OBJECTIVES

This systematic review aims to provide an overview of the intervention components, the targeted outcomes, the effectiveness in improving patient and informal caregiver outcomes, and the implementation into clinical practice.

METHODS

We systematically searched PubMed (MEDLINE), EMBASE, CENTRAL, PsycINFO, and CINAHL in March 2023. The studies included described interventions in palliative care, with multiple components, targeting patients with hematological cancer and/or their informal caregivers, and producing primary data on effectiveness or implementation. Quality was assessed using the QualSyst tool.

RESULTS

We identified 19 reports on 16 different palliative care interventions, including 4 quasi-randomized controlled trials. These interventions were provided by secondary and tertiary palliative care providers in a hospital setting. Tertiary interventions significantly improved the most common patient outcomes, including pain, quality of life, symptom burden, depression, and anxiety. Meanwhile, secondary interventions were feasible and well-accepted by healthcare professionals and patients. Despite limited inclusion of informal caregivers, the results indicated significant improvements in quality of life and depression.

CONCLUSION

While palliative care interventions are found to improve patient outcomes, future research is needed on the effectiveness of secondary palliative care interventions, integrating primary palliative care, and more reliable and frequent implementation measurements. More focus on informal caregivers and resource allocation based on patient needs is warranted.

Utilization and quality of palliative care in patients with hematological and solid cancers: a population-based study

BACKGROUND

Palliative care (PC) contributes to improved end-of-life care for patients with hematologic malignancies (HM) and solid tumors (ST) by addressing physical and psychological symptoms and spiritual needs. Research on PC in HM vs. ST patients is fragmented and suggests less use.

METHODS

We analyzed claims data of all deceased members of a large German health insurance provider for the year before death. First, we analyzed the frequency and the beginning of different types of PC and compared patients with HM vs. ST. Second, we analyzed the adjusted impact of PC use on several end-of-life quality outcomes in patients with HM vs. ST. We performed simple and multiple (logistic) regression analysis, adjusted for relevant covariates, and standardized for age and sex.

RESULTS

Of the 222,493 deceased cancer patients from 2016 to 2020, we included 209,321 in the first analysis and 165,020 in the second analysis. Patients with HM vs. ST received PC less often (40.4 vs. 55.6%) and later (34 vs. 50 days before death). PC use significantly improved all six quality indicators for good end-of-life care. HM patients had worse rates in five of the six indicators compared with ST patients. Interaction terms revealed that patients with ST derived greater benefit from PC in five of six quality indicators than those with HM.

CONCLUSION

The data highlight the need to integrate PC more often, earlier, and more effectively into the care of patients with HM.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Variability in the perception of palliative care and end-of-life care among hematology professionals from the same reference center in Bahia, Brazil: A descriptive cross-sectional study

BACKGROUND

There are several illness-specific cultural and system-based barriers to palliative care (PC) integration and end-of-life (EOL) care in the field of oncohematology.

OBJECTIVES

This study aimed to investigate the variability in the perceptions of PC and EOL care.

DESIGN AND SETTING

A cross-sectional study was conducted in the Hematology Division of our University Hospital in Salvador, Bahia, Brazil.

METHODS

Twenty physicians responded to a sociodemographic questionnaire and an adaptation of clinical questionnaires used in previous studies from October to December 2022.

RESULTS

The median age of the participants was 44 years, 80% of the participants identified as female, and 75% were hematologists. Participants faced a hypothetical scenario involving the treatment of a 65-year-old female with a poor prognosis acute myeloid leukemia refractory to first-line treatment. Sixty percent of the participants chose to follow other chemotherapy regimens, whereas 40% opted for PC. Next, participants considered case salvage for the patient who developed septic shock following chemotherapy and were prompted to choose their most probable conduct, and the conduct they thought would be better for the patient. Even though participants were from the same center, we found a divergence from the most probable conduct among 40% of the participants, which was due to personal convictions, legal aspects, and other physicians' reactions.

CONCLUSIONS

We found considerable differences in the perception of PC and EOL care among professionals, despite following the same protocols. The study also demonstrated variations between healthcare professionals' beliefs and practices and persistent historical tendencies to prioritize aggressive interventions.

The experience of patients with hematological malignancy in their terminal stage: a phenomenological study from Jordan's perspective

BACKGROUND

Patients diagnosed with hematological malignancies residing in low-middle-income countries undergo significant physical and psychological stressors. Despite this, only 16% of them receive proper care during the terminal stages. It is therefore crucial to gain insight into the unique experiences of this population.

AIM

To have a better understanding of the needs and experiences of adult patients with advanced hematological malignancy by exploring their perspectives.

METHODS

A qualitative interpretive design was employed to collect and analyze data using a phenomenological approach. The study involved in-depth interviews with ten participants aged between 49 and 65 years, utilizing a semi-structured approach.

RESULTS

Two primary themes emerged from the participants' experiences of reaching the terminal stage of illness: "Pain, Suffering, and Distress" and "Spiritual Coping." The first theme encompassed physical and emotional pain, suffering, and distress, while the second theme was centered on the participants' spiritual coping mechanisms. These coping mechanisms included seeking comfort in religious practices, relying on spiritual support from family and friends, and finding solace in their beliefs and faith.

CONCLUSION

Patients with hematological malignancies in the terminal stages of their disease experience severe pain, considerable physical and psychosocial suffering, and spiritual distress. While they require support to cope with their daily struggles, their experiences often go unnoticed, leading to disappointment and loss of dignity. Patients mainly rely on their spirituality to cope with their situations. Healthcare providers must acknowledge these patients' needs and provide more holistic and effective care.

Palliative Care in Patients With Hematological Malignancies. We Have a Long Way to Go…

Background: Patients with hematological malignancies have significant and diverse palliative care needs but are not usually referred to specialist palliative care services in a timely manner, if at all. Objective: To identify the characteristics of patients with hematological malignancies referred to the palliative care service in a tertiary hospital in Mexico City. Patients: Retrospective study including consecutive patients with hematological malignancies referred to palliative care services at Mexico's National Cancer Institute. Results: Between 2011 and 2019, 5,017 patients with hematological malignancies were evaluated for first time at Mexico's National Cancer Institute. Of these, 9.1% (n = 457) were referred to palliative care. Most were male (53.4%), with a median age of 58 years. The most frequent diagnosis was non-Hodgkin lymphoma (54.9%). The primary indication for referral to palliative care was for cases wherein chemotherapy was no longer an option (disease refractory to treatment, 42.8%). The median time of referral to the palliative care service occurred 11.2 months after the first evaluation at the National Cancer Institute and death occurred on median 1.1 months after the first palliative care evaluation. Conclusion: Patients with hematological neoplasms are infrequently referred to Palliative Care at the Institute (9.1%). We found no clear referral criteria for Palliative Care referral and note that hematologists' optimism regarding a cure can delay referrals. Clearly, we have a long way to go in improving the number of patients referred, and we still saw frequent referrals near the end of life, but the high rate of outpatient referrals is encouraging.

Developing a supportive and palliative care intervention for patients with allogeneic stem cell transplantation: protocol of a multicentre mixed-methods study (allo-PaS)

INTRODUCTION

Although allogeneic stem cell transplantation (allo-SCT) is a curative treatment for many haematological malignancies, it is often associated with a high morbidity and mortality. Yet, little is known about the needs for supportive and palliative care among allo-SCT recipients. Moreover, targeted interventions that reduce symptom burden and suffering are still lacking. The present study aims to inform a supportive-palliative care intervention for patients with allo-SCT and their informal carers by exploring their experience and assessing their needs, especially their existential concerns, regarding four research topics: symptom burden and quality of life; coexistence of a chance for cure and a relevant risk of dying; change in goals of care; dying phase.

METHODS AND ANALYSIS

This is a descriptive mixed-methods study in progress with a convergent parallel design. Data on the four research topics will be collected and analysed separately in three steps: (1) qualitative semi-structured interviews among 20 patients, 20 informal carers and 12 healthcare providers (HCPs) and focus groups among 12-24 HCPs; (2) a quantitative cross-sectional survey with validated questionnaires and self-developed questions among 100 patients, 100 informal carers and 50 HCPs; (3) a retrospective case analysis of all deceased patients who underwent an allo-SCT between 2010 and 2019, with collection of quantitative and qualitative data. The qualitative and quantitative data sets will be finally merged for comparison and interpretation. Results will serve to develop a supportive-palliative care intervention.

ETHICS AND DISSEMINATION

The Ethics Commission of the Faculty of Medicine of the University of Cologne approved this study (20-1370_2). The study results will be published in peer-review journals, be presented at congresses and will be translated into clinical practice through the development of the palliative-supportive care intervention.

TRIAL REGISTRATION NUMBER

DRKS00027290 (German Clinical Trials Register).

Factors associated with suffering from dying in patients with cancer: a cross-sectional analytical study among bereaved caregivers

BACKGROUND

In Colombia, cancer incidence is increasing, as is the demand for end-of-life care. Understanding how patients who die from cancer experience this phase will allow the identification of factors associated with greater suffering and actions to improve end-of-life care. We aimed to explore associations between the level of suffering of patients who died from cancer and were cared for in three Colombian hospitals with patient, tumor, treatment, and care characteristics and provided information.

METHODS

Data on the last week of life and level of suffering were collected through proxies: Bereaved caregivers of patients who died from cancer in three participating Colombian hospitals. Bereaved caregivers participated in a phone interview and answered a series of questions regarding the last week of the patient's life. An ordinal logistic regression model explored the relationship between the level of suffering reported by bereaved caregivers with the patient's demographic and clinical characteristics, the bereaved caregivers, and the care received. Multivariate analyses were adjusted for place of death, treatments to prolong of life, prolongation of life during the dying process, suffering due to prolongation of life, type of cancer, age, if patient had partner, rural/urban residence of patient, importance of religion for the caregiver, caregivers´ relationship with the patient, and co-living with the patient.

RESULTS

A total of 174 interviews were included. Median age of the deceased patients was 64 years (IQR 52-72 years), and 93 patients were women (53.4%). Most caregivers had rated the level of suffering of their relative as "moderately to extremely" (n = 139, 80%). In multivariate analyses, factors associated with a higher level of suffering were: unclear information about the treatment and the process before death Odds Ratio (OR) 2.26 (90% CI 1.21-4.19), outpatient palliative care versus home care OR 3.05 (90% CI 1.05-8.88), procedures inconsistent with the patient's wishes OR 2.92 (90% CI 1.28-6.70), and a younger age (18-44 years) at death versus the oldest age group (75-93 years) OR 3.80 (90% CI 1.33-10.84, p = 0.04).

CONCLUSION

End-of-life care for cancer patients should be aligned as much as possible with patients´ wishes, needs, and capacities. A better dialogue between doctors, family members, and patients is necessary to achieve this.

Haematological nurses' experiences about palliative care trajectories of patients with life-threatening haematological malignancies: A qualitative study

AIMS

To explore haematological nurses' experiences about the palliative care trajectories of patients with life-threatening haematological malignancies.

DESIGN

A qualitative study with a descriptive and explorative design.

METHODS

Data were collected through 12 individual semi-structured interviews of nurses who work with patients with haematological malignancies from four hospitals in Norway. The data were analysed using systematic text condensation. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.

RESULTS

Three categories emerged from the data analysis: focus on a cure delays integration of palliative care, dialogue with patients facilitates palliative care and the need for enhanced interdisciplinary understanding.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution since nurses' experiences were explored.

Providing Care to People Living with a Chronic Hematological Malignancy: A Qualitative Evidence Synthesis of Informal Carers' Experiences

OBJECTIVE

Chronic hematological malignancies such as multiple myeloma, chronic lymphocytic leukemia (CLL), indolent B-cell lymphomas, and myelodysplastic syndromes (MDS) have seen significant advances in treatment. Treatment developments have resulted in patients living for many years, often between periods of being acutely unwell, relapses, and remission. Informal carers play a major role in supporting patients through the uncertain and long illness trajectory. This qualitative evidence synthesis (QES) aims to synthesize qualitative research evidence on the experiences of informal carers caring for a patient with a chronic hematological malignancy (CHM).

DATA SOURCES

This qualitative evidence synthesis followed the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines and adopted a "best fit" framework synthesis approach using a "redefining normal" conceptual framework. A systematic search of seven databases was undertaken.

CONCLUSION

Sixteen qualitative studies were synthesized in this review. Eight review findings illuminated carers' unmet information needs, challenges with caring responsibilities, end-of-life care, and changes in the dyad carer-patient relationship.

IMPLICATIONS FOR NURSING PRACTICE

This best-fit framework synthesis illuminates the wide-ranging challenges experienced by informal caregivers of people living with a chronic hematological malignancy. Carers' fear for the future highlights the need for interventions to support them with their fears. Carers' priority on their loved one's quality of life is impaired by late end-of-life discussions often not occurring until a sudden deterioration in the patient's condition. Early supportive relationships between carers and health care providers can promote conversations on poor prognosis and end-of-life care. Future research should focus on qualitative longitudinal studies with caregiver-patient dyads.

Palliative care utilization, transfusion burden, and end-of-life care for patients with multiple myeloma

INTRODUCTION

Despite treatment advances, multiple myeloma (MM) remains a significant source of morbidity and mortality. We aimed to examine specialist palliative care (SPC) involvement and end-of-life care for patients with MM.

METHODS

We assessed all deceased patients with a diagnosis of MM who received care at a single institution from January 2010 to December 2019 and assessed SPC involvement.

RESULTS

We reviewed 456 deceased patients. Overall, 207 patients (45.4%) received SPC visits by clinicians during their disease, and 153 (33.5%) were on MM treatment in the month before death. Median time from SPC consultation to death was 1 month, with 42 (9.2%) of patients receiving SPC visits 6 or more months before death. Amongst the patients for which a place of death was reported (351), 117 (33.3%) died in the acute care setting. Outpatient SPC did not correlate with a reduction of death in the acute care setting. In the group of patients who received outpatient SPC, 22/84 (26.2%) died in an acute care setting, whereas 95/267 (35.5%) patients who did not receive outpatient SPC also died in an acute care setting, (p = .11).

CONCLUSION

In our analysis of the entire trajectory of the MM patient experience from diagnosis to death, we found low rates of SPC involvement and a significant proportion of patients receiving aggressive care at end-of-life. While there is no clear correlation that SPC involvement impacted the rate of acute care deaths or decreased utilization of MM treatment in the last month of life, further prospective research on optimal utilization of SPC is required.

Development of a screening tool for the need of specialist palliative care in oncologic inpatients: study protocol for the ScreeningPALL Study

INTRODUCTION

A range of referral criteria and scores have been developed in recent years to help with screening for the need of specialist palliative care (SPC) in advanced, incurable cancer patients. However, referral criteria have not yet been widely implemented in oncology, as they usually need to be revised by physicians or nurses with limited time resources. To develop an easily applicable screening for the need for SPC in incurable cancer inpatients, we aim to (a) test inter-rater reliability of multiprofessional expert opinion as reference standard for SPC need (phase I) and (b) explore the diagnostic validity of selected patient-reported outcome measures (PROMs) and routine data for the need of SPC (phase II).

METHODS AND ANALYSIS

Inclusion criteria for patients are metastatic or locally advanced, incurable cancer, ≥18 years of age and informed consent by patient or proxy. (Exclusion criteria: malignant haematological disease as main diagnosis). In phase I, three palliative care consultation teams (PCTs) of three German university hospitals assess the SPC need of 20 patient cases. Fleiss' Kappa will be calculated for inter-rater reliability. In phase II, 208 patients are consecutively recruited in four inpatient oncology wards of Freiburg University Hospital. The PCT will provide assessment of SPC need. As potential referral criteria, patients complete PROMs and a selection of routine data on person, disease and treatment is documented. Logistic regression models and ROC analyses are employed to test their utility in screening for SPC need.

ETHICS AND DISSEMINATION

Our findings will be published in peer-reviewed journals and presented at national and international scientific meetings and congresses. Ethical approval was granted by the Ethics Committee of Albert-Ludwigs-University Freiburg, Germany (approval no. 20-1103).

TRIAL REGISTRATION NUMBER

German Clinical Trials Register, DRKS00021686, registered on 17 December 2020.

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.

Clinicians' Understanding of Preferences and Values of People with Hematological Malignancies at the End of Life: Concurrent Surveys

Background: People with hematological malignancies can deteriorate rapidly to a terminal event and have variable levels of engagement when transitioning to palliative and end-of-life care. Objectives: To describe end-of-life care values and preferences of people with hematological malignancies and explore whether these align with hematology clinicians' perceptions. Design: Two matched anonymous quantitative cross-sectional surveys explored: (1) patients' values and preferences around manner and timing of discussions regarding life expectancy and prognosis, involvement in decision making, and concurrent integration of palliative care with active treatment; and (2) clinicians' perceptions of their patients' values and preferences in relation to prognostic information. Settings/Participants: Concurrent online national surveys of people with hematological malignancies known to the Leukemia Foundation of Australia, and clinicians in Australia with membership to the Hematology Society of Australia and New Zealand. Results: Five hundred nine (38% response rate) patients (median age 64 [min 20, max 89, interquartile range 56-70]) and 272 clinicians (21% response rate) responded to the survey. If their health was deteriorating, most patients wanted honest prognostic and life expectancy information (87%); welcomed involvement in decision making (94%); felt they would be comfortable talking to the treating team about the possibility of death (86%); and would be comfortable seeing someone from a specialist palliative care team (74%). Clinicians generally underestimated most of these responses. Conclusion: Although our findings indicate that most people believe they would be comfortable discussing prognosis, life expectancy, and wishes at the end of life, clinicians were largely unaware of their preferences. This highlights the need to embed values clarification in routine care for each patient and family.

Palliative care for patients around the time of haematopoietic stem cell transplant: a qualitative study of patients' perceptions and experiences of unmet need and attitudes towards palliative care involvement

BACKGROUND

Haemato-oncology patients are likely to be referred later to palliative care than patients with solid tumours, despite experiencing similar symptom burden. Patients prior to stem cell transplant may benefit from symptom control, advance care planning and shared decision-making, and previous studies have demonstrated feasibility and benefit of such a service. However, the views of patients are not yet established, and are vital to ensure acceptability of the service.

AIMS

To identify areas where a palliative care team may help to support patients being considered for a stem cell transplant, and to explore the attitudes and perceptions of patients towards palliative care at this time.

DESIGN

A qualitative study including interviews (N = 12) and a focus group (N = 4) for patients pre- and post-transplant, using a semi-structured format via telephone, online video-conferencing and face-to-face discussions. Recordings were transcribed and analysed using thematic analysis.

SETTING

A tertiary cancer centre in the UK.

FINDINGS

Themes identified were the following: Identified needs, Information and decision-making, Importance of relationships, Changing perceptions of what palliative care means, and The future. Patients associate palliative care with terminal care due to indirect experiences. Patients were open to palliative care once its purpose was explained and described emotional and physical needs relevant to early palliative care.

CONCLUSIONS

The involvement of early palliative care alongside haematology treatment prior to stem cell transplant may improve quality of life for patients and facilitate shared decision-making at a crucial stage of treatment. Early palliative care should be offered alongside haematology care around the time of stem cell transplant, with information provided to patients regarding its role.

Outcomes of Specialty Palliative Care Interventions for Patients With Hematologic Malignancies: A Systematic Review

CONTEXT

The outcomes of specialty palliative care (PC) interventions for patients with hematologic malignancies (HMs) is under-investigated.

OBJECTIVES

We performed a systematic review to evaluate the effect of PC interventions on patient- and caregiver- reported outcomes and healthcare utilization among adults with HMs (leukemia, myeloma, and lymphoma).

METHODS

From database inception through September 10, 2020, we systematically searched PubMed, CINAHL, Embase, Scopus, Web of Science, and Cochrane Reviews using terms representing HMs and PC. Eligible studies investigated adults aged 18 years and older, were published in the English language, and contained original, quantitative, or qualitative data related to patient- and/or caregiver-centered outcomes and healthcare utilization.

RESULTS

We screened 5345 studies;16 met inclusion criteria and found that specialty PC led to improved symptom management, decreased likelihood of inpatient death, decreased healthcare utilization, decreased cost of healthcare, and improved caregiver-reported outcomes. Patients with HM have a high need for PC which, though increasing over time, is often provided late in the clinical disease course.

CONCLUSIONS

Specialty PC interventions improve healthcare outcomes for patients with HMs and should be implemented early and often. There remains a need for additional studies investigating PC use exclusively in patients with HMs.

Prospective observational study of palliative care in hematological malignancies: Report of one year of practice

INTRODUCTION

Palliative care is an approach that improves the quality of life of patients with advanced disease.

OBJECTIVE

The aim of this study is to evaluate the process of palliative care in patients with hematologic malignancies.

METHODS

In this prospective observational study, we included patients with hematologic malignancies who received palliative care over a 12 month period from June 1, 2019, to May 31, 2020 at the day care hospital of the hematology department in University Hospital of Sfax, Tunisia. Blood transfusion was used to relieve symptoms of anemia and bleeding.

RESULTS

Fifty-five patients were included. The median age was 68 years. Forty-three percent of patients were diagnosed with acute leukemia and 41.8% with myelodysplastic syndrome. Red cell and platelet transfusions were indicated in 94.5% and 36.3% of cases respectively. Patients reported improvement after blood transfusion in 50% of cases. Twenty-five transfusion reactions (45%) were noted. Fever was noted in 33 patients (60%), with documented sites of infection in 84.8% of them. Pulmonary infection was frequently noted (50%). Antimicrobial treatment was prescribed in all febrile cases. Pain was reported in 22 patients and in 77.5% of these cases, it was nociceptive. Patients who received analgesics showed clinical improvement in pain in 81% of cases. Anorexia with malnutrition was reported in 23% of cases which was treated with enteral nutrition in 75% of cases. Sleep disturbance (20 patients), anxiety (7 patients), and depression (4 patients) were mentioned respectively.

CONCLUSION

Palliative care in hematology should be a multidisciplinary care approach with a global management of the various physical, psychological and sociological complications.

Palliative care referral in cancer patients with regard to initial cancer prognosis: a population-based study

OBJECTIVES

More than half of cancer patients require palliative care; however, inequality in access and late referral in the illness trajectory are major issues. This study assessed the cumulative incidence of first hospital-based palliative care (HPC) referral, as well as the influence of patient-, tumor-, and care-related factors.

STUDY DESIGN

This is a retrospective population-based study.

METHODS

The study included patients from the 2014 population-based cancer registry of Gironde, France. International Classification of Diseases, Tenth Revision, coding for palliative care identified HPC referrals from 2014 to 2018. The study included 8424 patients. Analyses considered the competing risk of death and were stratified by initial cancer prognosis (favorable vs unfavorable [if metastatic or progressive cancer]).

RESULTS

The 4-year incidence of HPC was 16.7% (95% confidence interval, 16.6-16.8). Lung cancer led to more referrals, whereas breast, colorectal, and prostatic locations were associated to less frequent HPC compared with other solid tumors. Favorable prognosis central nervous system tumors and unfavorable prognosis hematological malignancies also showed less HPC. The incidence of HPC was higher in tertiary centers, particularly for older patients. In the favorable prognosis subgroup, older and non-deprived patients received more HPC. In the unfavorable prognosis subgroup, the incidence of HPC was lower in patients who lived in rural areas than those who lived in urban areas.

CONCLUSIONS

One-sixth of cancer patients require HPC. Some factors influencing referral depend on the initial cancer prognosis. Our findings support actions to improve accessibility, especially for deprived patients, people living in rural areas, those with hematological malignancies, and those treated outside tertiary centers. In addition, consideration of age as factor of HPC may allow for improved design of the referral system.

What is known about palliative care in adult patients with allogeneic stem cell transplantation (allo-SCT)?

Patients undergoing allogeneic stem cell transplantation (allo-SCT) are given a real chance of cure, but at the same time are confronted with a considerable risk of mortality and of severe long-term impediments. This narrative, non-systematic literature review aims to describe the supportive and palliative care needs of allo-SCT recipients, including long-term survivors or those relapsing or dying after transplantation. It also evaluates the feasibility and effectivity of integrating palliative care early in transplant procedures. In this appraisal of available literature, the main findings relate to symptoms like fatigue and psychological distress, which appear to be very common in the whole allo-SCT trajectory and might even persist many years post-transplantation. Chronic GvHD has a major negative impact on quality of life. Overall, there is a paucity of research on further issues in the context of allo-SCT, like the distress related to the frequently unpredictable post-transplant trajectory and prognosis, as well as the end-of-life phase. First randomized controlled results support the effectiveness of early integration of specialized palliative care expertise into transplant algorithms. Barriers to this implementation are discussed.

Effects of family participatory dignity therapy on the psychological well-being and family function of patients with haematologic malignancies and their family caregivers: A randomised controlled trial

BACKGROUND

Strong family ties appear to buffer patient's and family members' difficult experiences during life and health crises. The family participatory dignity therapy programme, a patient-family-centred psychological intervention, was developed based on dignity therapy and performed by one therapist in the form of interview according to a specific question prompt.

OBJECTIVES

This study aimed to confirm the efficacy of the family participatory dignity therapy programme in improving the psychological well-being and family cohesion and adaptability of patients with haematologic malignancies and their family caregivers.

DESIGN

A single-blinded, two-arm parallel group, randomised controlled trial was conducted.

SETTING(S)

and Participants: Participants were patient-family caregiver dyads recruited from Fujian Medical University Union Hospital from March to September 2019.

METHODS

A total of 68 eligible dyads agreed to participate and were randomly assigned to the intervention group (n = 33) or control group receiving usual care (n = 35). Each pair of patient-family dyads in the intervention group received two or three interviews (each interview approximately lasting 45 to 60 min) performed by one therapist according to a specific question prompt containing 10 questions for patients and 10 corresponding questions for their family caregivers. To evaluate the effects of the intervention, we assessed patients' hope, spiritual well-being, and family cohesion and adaptability, as well as their family caregivers' depression, anxiety, and family cohesion and adaptability at baseline (T0), 1 week (T1), 4 weeks (T2), and 8 weeks post-intervention (T3) and compared the scores between the groups. A two-way repeated-measures analysis of variance was conducted to examine the effects of time, group, and their interaction.

RESULTS

For patients, there was a significant difference in hope (p = 0.001), spiritual well-being (p = 0.002), and family cohesion (p<0.001) and adaptability (p<0.001) between the intervention and control groups. The difference over time was also significant in family cohesion (p = 0.018) and adaptability (p = 0.003). The interaction effects were significant for hope (p = 0.034), spiritual well-being (p<0.001), and family cohesion (p<0.001) and adaptability (p<0.001). For family caregivers, there was a significant difference in anxiety (p = 0.037), depression (p = 0.001), and family adaptability (p = 0.036) between the intervention and control groups. Within groups, a significant difference in family adaptability (p = 0.012) was found. Moreover, the interaction effects were significant on anxiety (p = 0.001) and family cohesion (p = 0.038).

CONCLUSIONS

The family participatory dignity therapy programme showed a positive effect on promoting patients' hope, spiritual well-being, and family cohesion and adaptability; amongst family caregivers, it decreased anxiety and depression, and enhanced family cohesion and adaptability. Registration number: ChiCTR1900021433 Tweetable abstract: The family participatory dignity therapy programme promoted patients' hope, spiritual well-being, and family cohesion and adaptability, decreased their family caregivers' anxiety and depression, and enhanced the caregivers' family cohesion and adaptability.

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.

Early palliative care in haematological patients: a systematic literature review

Background

Early palliative care together with standard haematological care for advanced patients is needed worldwide. Little is known about its effect. The aim of the review is to synthesise the evidence on the impact of early palliative care on haematologic cancer patients’ quality of life and resource use.

Patients and methods

A systematic review was conducted. The search terms were early palliative care or simultaneous or integrated or concurrent care and haematological or oncohaematological patients. The following databases were searched: PubMed, Embase, Cochrane, CINHAL and Scopus. Additional studies were identified through cross-checking the reference articles. Studies were in the English language, with no restriction for years. Two researchers independently reviewed the titles and abstracts, and one author assessed full articles for eligibility.

Results

A total of 296 studies titles were reviewed. Eight articles were included in the synthesis of the results, two controlled studies provided data on the comparative efficacy of PC interventions, and six one-arm studies were included. Since data pooling and meta-analysis were not possible, only a narrative synthesis of the study results was performed. The quality of the two included comparative studies was low overall. The quality of the six non-comparative studies was high overall, without the possibility of linking the observed results to the implemented interventions.

Conclusions

Studies on early palliative care and patients with haematological cancer are scarce and have not been prospectively designed. More research on the specific population target, type and timing of palliative care intervention and standardisation of collected outcomes is required.

PROSPERO registration number

CRD42020141322.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

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.

Palliative versus hospice care in patients with cancer: a systematic review

BACKGROUND

Guidelines recommend an early access to specialised palliative medicine services for patients with cancer, but studies have reported a continued underuse. Palliative care facilities deliver early care, alongside antineoplastic treatments, whereas hospice care structures intervene lately, when cancer-modifying treatments stop.

AIM

This review identified factors associated with early and late interventions of specialised services, by considering the type of structures studied (palliative vs hospice care).

DESIGN

We performed a systematic review, prospectively registered on PROSPERO (ID: CRD42018110063).

DATA SOURCES

We searched Medline and Scopus databases for population-based studies. Two independent reviewers extracted the data and assessed the study quality using Joanna Briggs Institute critical appraisal checklists.

RESULTS

The 51 included articles performed 67 analyses. Most were based on retrospective cohorts and US populations. The median quality scores were 19/22 for cohorts and 15/16 for cross-sectional studies. Most analyses focused on hospice care (n=37). Older patients, men, people with haematological cancer or treated in small centres had less specialised interventions. Palliative and hospice facilities addressed different populations. Older patients received less palliative care but more hospice care. Patients with high-stage tumours had more palliative care while women and patients with a low comorbidity burden received more hospice care.

CONCLUSION

Main disparities concerned older patients, men and people with haematological cancer. We highlighted the challenges of early interventions for older patients and of late deliveries for men and highly comorbid patients. Additional data on non-American populations, outpatients and factors related to quality of life and socioeconomic status are needed.

Caregivers of Patients with Hematological Malignancies within Home Care: A Phenomenological Study

The role of caregivers in homecare settings is relevant to the patient’s wellbeing and quality of life. This phenomenon is well described in the literature for the oncological setting but not specifically for that of hematological malignancies. The aim of this study was to explore the experience of primary caregivers of patients with hematological malignancies within home care. We conducted a phenomenological study based on interviews with 17 primary caregivers of hematological patients. Analysis of the contents led to the identification of five main themes. Perhaps, the innovative aspects of this study can be summarized in three points: This service was demonstrated to fulfil the ethical aspects of providing the patient with a dignified accompaniment to the end of life. Secondly, the efficiency of the service and the benefit are directly dependent on the caregivers’ wellbeing, so knowledge of the dynamics and emotions involved can lead to the development and implementation of programs for hematological malignancies. Lastly, a collaborative caregivers–professionals relationship can improve a sense of accomplishment for all parties involved, lessening the family’s frustration related to not having done their best. Home care brings significant benefits for both the patient and the caregivers and fulfils the ethical obligation of providing the patient dignified end-of-life care.

Sociodemographic and clinical factors for non-hospital deaths among cancer patients: A nationwide population-based cohort study

BACKGROUND

Factors associated with place of death inform policies with respect to allocating end-of-life care resources and tailoring supportive measures.

OBJECTIVE

To determine factors associated with non-hospital deaths among cancer patients.

DESIGN

Retrospective cohort study of cancer decedents, examining factors associated with non-hospital deaths using multinomial logistic regression with hospital deaths as the reference category.

SETTING/SUBJECTS

Cancer patients (n = 15254) in Singapore who died during the study period from January 1, 2012 till December 31, 2105 at home, acute hospital, long-term care (LTC) or hospice were included.

RESULTS

Increasing age (categories ≥65 years: RRR 1.25-2.61), female (RRR 1.40; 95% CI 1.28-1.52), Malays (RRR 1.67; 95% CI 1.47-1.89), Brain malignancy (RRR 1.92; 95% CI 1.15-3.23), metastatic disease (RRR 1.33-2.01) and home palliative care (RRR 2.11; 95% CI 1.95-2.29) were associated with higher risk of home deaths. Patients with low socioeconomic status were more likely to have hospice or LTC deaths: those living in smaller housing types had higher risk of dying in hospice (1-4 rooms apartment: RRR 1.13-3.17) or LTC (1-5 rooms apartment: RRR 1.36-4.11); and those with Medifund usage had higher risk of dying in LTC (RRR 1.74; 95% CI 1.36-2.21). Patients with haematological malignancies had increased risk of dying in hospital (categories of haematological subtypes: RRR 0.06-0.87).

CONCLUSIONS

We found key sociodemographic and clinical factors associated with non-hospital deaths in cancer patients. More can be done to enable patients to die in the community and with dignity rather than in a hospital.

Psychological and Financial Distress Management in Adults With Acute Leukemia

OBJECTIVES

To review and summarize psychological and financial distress in adults with acute leukemia and provide evidence-based methods that nurses can apply to alleviate distress experienced by patients.

DATA SOURCES

Oncology and palliative care literature published over the past decade.

CONCLUSION

Current evidence supports the efficacy of psychosocial interventions to improve psychological well-being and reduce distress for adults undergoing treatment for leukemia.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a critical role, not only in identifying patients who are experiencing impaired psychological well-being and high levels of distress, but also in providing prompt support to these patients.

Palliative Care for Patients With Hematologic Malignancies in a Low-Middle Income Country: Prevalence of Symptoms and the Need for Improving Quality of Attention at the End of Life

BACKGROUND

Palliative care (PC) for patients with malignant hematological diseases is scarcely documented, particularly in low- and middle-income countries. This study aimed to document PC provided to patients with hematologic malignancies.

METHODS

Bidirectional study conducted from July 2016 to June 2019 at the hematology and palliative care departments at a reference center in Northeast Mexico for low-income open population uninsured patients. Clinical records and electronic files of patients with malignant hematological diseases of both sexes and all ages attending an academic hematology center were reviewed. Statistical analysis was performed with the SPSS version 22 program. Acute and chronic leukemias, multiple myeloma, Hodgkin lymphoma, non-Hodgkin lymphoma, and others were included.

RESULTS

Five-hundred ten patients were studied, of which 148 (29%) died. Eighty-one (15.88%) patients including 31 (20.9%) who died received PC. Median age at palliative diagnosis was 42 (2-91) years. The most common symptom was pain (69.7%). The most frequent reason for palliative referral was treatment-refractory disease (39%). During the last week of life, 19 (95%) of 20 patients had blood sampling; 17 (85%) received antibiotics; 16 (80%) had a urinalysis performed; 16 (80%) received analgesia, including paracetamol (11, 35.5%) and buprenorphine (7, 22.6%); 10 (50%) received blood products; 9 (45%) were intubated; and central venous catheters were inserted in 5 (25%) patients.

CONCLUSIONS

Palliative care was provided to a minority of patients with hematologic malignancies and considerable improvement is required in its timely use and extension.

Illness Understanding and Advance Care Planning in Patients with Advanced Lymphoma

Background: The prognosis of an aggressive lymphoma can change dramatically following failure of first-line treatment. This sudden shift is challenging for the promotion of illness understanding and advance care planning (ACP). Yet, little is known about illness understanding and ACP in patients with aggressive lymphomas. Objective: To examine illness understanding, rates of engagement in ACP, and reasons for lack of ACP engagement in patients with advanced B cell lymphomas. Design: Cross-sectional observational study. Setting/Subjects: Patients (n = 27) with aggressive B cell lymphomas that relapsed after first- or second-line treatment treated at a single urban academic medical center. Measurements: Participants were administered structured surveys by trained staff to obtain self-report measures of illness understanding (i.e., aggressiveness, terminality, curability) and ACP (i.e., discussions of care preferences, completion of advance directives). Results: The majority of patients reported discussing curability (92.6%), prognosis (77.8%), and treatment goals (88.9%) with their medical team. Yet, less than one-third of patients reported being terminally ill (29.6%) and having incurable disease (22.2%). Most patients had a health care proxy (81.5%) and had decided about do-not-resuscitate status (63%), but the majority had not completed a living will (65.4%) or discussed their care preferences with others (55.6%). Conclusions: The accuracy of lymphoma patients' illness understanding following first-line treatment is difficult to determine due to the potential for cure following transplant. However, this study suggests that a large proportion of patients with advanced B cell lymphomas may underestimate the severity of their illness, despite discussing illness severity with their medical team. Providing patients with information on prognosis, and the ACP process may increase engagement in ACP.

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.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Video consultations in palliative care: A systematic integrative review

BACKGROUND

There is extensive need for palliative care worldwide, but access to care remains inadequate, especially for non-cancer patients. Video consultations are a promising tool in the provision of home-based palliative care, but an overview of evidence solely on video consultations in palliative care is lacking.

AIM

To review and synthesize current evidence regarding the use of video consultations in general and specialized palliative care to various patient groups.

DESIGN

A systematic integrative review with a narrative synthesis was undertaken in accordance with PRISMA (2009) guidelines. PROSPERO #: CRD42018095383.

DATA SOURCES

PubMed, Embase, CINAHL, and PsychINFO were searched for primary research articles published between 2005 and 2018. In addition, reference lists of included articles were hand searched.

RESULTS

The search resulted in 813 articles; 39 articles were included in the review, consisting of mixed methods (n = 14), qualitative (n = 10), quantitative (n = 10), and case studies (n = 5). The studies mainly focused on specialized palliative care to adult patients with cancer in high income countries. Through data analysis, six themes addressing advantages/disadvantages and facilitators/barriers were identified: (1) Redesign of care, (2) Communication, (3) User perceptions, (4) Technology, (5) Privacy issues, and (6) Economic implications.

CONCLUSION

Using video technology in palliative care has both advantages and disadvantages. However, evidence beyond the focus on specialized palliative care and patients with cancer is limited. Future research should focus on how and when video consultations might replace in-person specialized palliative care and video consultations in general palliative care, in low and middle income countries; and involve patients with a non-cancer diagnosis.

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.

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.

Disparities in place of death for patients with hematological malignancies, 1999 to 2015

Patients with hematologic malignancies (HMs) often receive aggressive end-of-life care and less frequently use hospice. Comprehensive longitudinal reporting on place of death, a key quality indicator, is lacking. Deidentified death certificate data were obtained via the National Center for Health Statistics for all HM deaths from 1999 to 2015. Multivariate regression analysis (MVA) was used to test for disparities in place of death associated with sociodemographic variables. During the study period, there were 951 435 HM deaths. Hospital deaths decreased from 54.6% in 1999 to 38.2% in 2015, whereas home (25.9% to 32.7%) and hospice facility deaths (0% to 12.1%) increased (all P < .001). On MVA of all cancers, HM patients had the lowest odds of home or hospice facility death (odds ratio [OR], 0.55; 95% confidence interval, 0.54-0.55). Older age (40-64 years: OR, 1.34; ≥65 years: OR, 1.89), being married (OR, 1.62), and having myeloma (OR, 1.34) were associated with home or hospice facility death, whereas being black or African American (OR, 0.68), Asian (OR, 0.58), or Hispanic (OR, 0.84) or having chronic leukemia (OR, 0.83) had decreased odds of dying at home or hospice (all P < .001). In conclusion, despite hospital deaths decreasing over time, patients with HMs remained more likely to die in the hospital than at home.

Palliative Care in Patients with Hematological Malignancies

Patients with hematologic malignancies (HM) nowadays rarely receive palliative or hospice care, and studies on potential effects of integrated palliative care are rare. This narrative review provides a comprehensive overview on their current end-of-life care, first data on integrated specialist palliative care (SPC) and potential barriers. Symptom burden and distress in patients with HM seem to be comparable to other cancer patients, but their performance status and specific symptoms are even worse. Prolongation of life usually remains the main focus until the last days or weeks of life. Their chance to die in hospital is twice as high, but their chance to receive specialist palliative or hospice care is only half of that of other cancer patients. Prospective studies indicate a high acceptability and positive effects of integrated SPC, e.g. clarification of treatment goals, stabilization of quality of life, decreased depression, anxiety, symptom burden, and post-traumatic stress disorders. Interdisciplinary cooperation, timely discussions about SPC referral, and indicators to 'flag' patients in need for SPC are important, but they are largely missing. In conclusion, further studies have to evaluate factors identifying patients with HM in need for SPC. Further models of early integrated palliative care should be evaluated in prospective studies and established in daily clinical practice.

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.

Palliative care specialists' perceptions concerning referral of haematology patients to their services: findings from a qualitative study

BACKGROUND

Haematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals.

METHODS

We conducted a qualitative study, set within the United Kingdom's (UK's) Haematological Malignancy Research Network (HMRN: www.hmrn.org ), a population-based cohort in the North of England. In-depth, semi-structured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the 'Framework' method.

RESULTS

Study participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of inter-disciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to 'flag' patients' needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time.

CONCLUSIONS

This is the first UK study to explore SPC practitioners' perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral.