1
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Malakian A, Rodin G, Widger K, Ali R, Mahendiran AE, Mayo SJ. Experience of Care Among Adults With Acute Leukemia Near the End of Life: A Scoping Review. J Palliat Med 2024; 27:255-264. [PMID: 37738328 DOI: 10.1089/jpm.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Abstract
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.
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Affiliation(s)
- Argin Malakian
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Gary Rodin
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care, University Health Network (UHN), Toronto, Ontario, Canada
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Lifespan Program, ICES, Toronto, Ontario, Canada
| | - Ridwaanah Ali
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Angela E Mahendiran
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Samantha J Mayo
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
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2
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Patel RV, Ali F, Chiad Z, Chojecki AL, Webb JA, Rosa WE, LeBlanc TW. Top Ten Tips Palliative Care Clinicians Should Know About Acute Myeloid Leukemia. J Palliat Med 2023. [PMID: 38064538 DOI: 10.1089/jpm.2023.0638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults. Rapidly proliferating leukemic cells cause symptoms and increase the risk of infection. While individuals may initially benefit from supportive measures, disease-directed therapy may ultimately be required for symptom management, even at the end of life, although this may also inadvertently increase symptom burden. This unpredictable illness trajectory complicates prognostic uncertainty and the timing of hospice referral, which may prohibit access to palliative therapies and lead to recurrent hospitalizations. However, emerging evidence demonstrates that early palliative care (PC) integration with standard leukemia care results in improved quality of life, psychological outcomes, and greater participation in advance care planning. To orient PC clinicians asked to care for patients with AML, this article highlights 10 salient considerations.
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Affiliation(s)
- Rushil V Patel
- Division of Hematology and Oncology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fatima Ali
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Zane Chiad
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | | | - Jason A Webb
- Section of Palliative Care, Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas W LeBlanc
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
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3
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Stempel JM, Podoltsev NA, Dosani T. Supportive Care for Patients With Myelodysplastic Syndromes. Cancer J 2023; 29:168-178. [PMID: 37195773 DOI: 10.1097/ppo.0000000000000661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes are a heterogeneous group of bone marrow disorders characterized by ineffective hematopoiesis, progressive cytopenias, and an innate capability of progressing to acute myeloid leukemia. The most common causes of morbidity and mortality are complications related to myelodysplastic syndromes rather than progression to acute myeloid leukemia. Although supportive care measures are applicable to all patients with myelodysplastic syndromes, they are especially essential in patients with lower-risk disease who have a better prognosis compared with their higher-risk counterparts and require longer-term monitoring of disease and treatment-related complications. In this review, we will address the most frequent complications and supportive care interventions used in patients with myelodysplastic syndromes, including transfusion support, management of iron overload, antimicrobial prophylaxis, important considerations in the era of COVID-19 (coronavirus infectious disease 2019), role of routine immunizations, and palliative care in the myelodysplastic syndrome population.
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4
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Korsos V, Ali A, Malagon T, Khosrow-Khavar F, Thomas D, Sirhan S, Davison K, Assouline S, Cassis C. End of life in haematology: quality of life predictors - retrospective cohort study. BMJ Support Palliat Care 2023:spcare-2023-004218. [PMID: 37068924 DOI: 10.1136/spcare-2023-004218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/15/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES Haematology patients are more likely to receive high intensity care near end of life (EOL) than patients with solid malignancy. Previous authors have suggested indicators of quality EOL for haematology patients, based on a solid oncology model. We conducted a retrospective chart review with the objectives of (1) determining our performance on these quality EOL indicators, (2) describing the timing of level of intervention (LOI) discussion and palliative care (PC) consultation prior to death and (3) evaluating whether goals of therapy (GOT), PC consultation and earlier LOI discussion are predictors of quality EOL. METHODS We identified patients who died from haematological malignancies between April 2014 and March 2016 (n=319) at four participating McGill University hospitals and performed retrospective chart reviews. RESULTS We found that 17% of patients were administered chemotherapy less than 14 days prior to death, 20% of patients were admitted to intensive care, 14% were intubated and 5% were resuscitated less than 30 days prior to death, 18% of patients received blood transfusion less than 7 days prior to death and 67% of patients died in an acute care setting. LOI discussion and PC consultation occurred a median of 22 days (IQR 7-103) and 9 days (IQR 3-19) before death. Patients with non-curative GOT, PC consultation or discussed LOI were significantly less likely to have high intensity EOL outcomes. CONCLUSIONS In this study, we demonstrate that LOI discussions, PC consults and physician established GOT are associated with quality EOL outcomes for patients with haematological malignancies.
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Affiliation(s)
- Victoria Korsos
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Alla'a Ali
- Rossy Cancer Network, Montreal, Quebec, Canada
| | - Talia Malagon
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Farzin Khosrow-Khavar
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
- Department of Biostatistics and Epidemiology, Rutgers University, New Brunswick, New Jersey, USA
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | | | - Shireen Sirhan
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Kelly Davison
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sarit Assouline
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Chantal Cassis
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
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5
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We were in the fight together: The expectations of bereaved caregivers of patients with acute myeloid leukemia from diagnosis to death. Leuk Res 2023; 124:106994. [PMID: 36481729 DOI: 10.1016/j.leukres.2022.106994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/09/2022] [Accepted: 11/24/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Patients with hematologic malignancies are more optimistic than their oncologists and their expectations may be a barrier to timely hospice care. Patient expectations toward the end of life (EOL), however, have not been characterized. In this study, we analyzed interviews of bereaved caregivers to understand the expectations of patients diagnosed with acute myeloid leukemia and the factors that influenced those expectations, from diagnosis until death. METHODS Bereaved caregivers (n = 19) participated in an in-depth interview that included open-ended and semi-structured prompts, within 18 months following patient death. Interviews were analyzed using a modified grounded theory qualitative approach and constant comparative methods. RESULTS We identified three themes relevant to expectations: Taking Stock, Being Stuck, and Disruption. Caregivers described clear and optimistic early expectations that AML is treatable. It was understood that treatment was required to survive. Later, when treatment options were limited, patients and caregivers became stuck in a belief that the patient could continue to live indefinitely on supportive care or at least until new more effective treatments were available. Caregivers often realized that the patient was at the end of life only when faced with a disruption, an event or conversation that changed their expectations for indefinite patient survival. CONCLUSIONS Caregivers described continued expectations for patient survival until presented with irrefutable evidence to the contrary. The study suggests patients and caregivers may make better EOL care decisions if their early optimism is deliberately moderated by ongoing conversations with clinicians that highlight the sentinel events that signal treatment failure and explain how expectations and goals are changing from living a longer life to dying a more comfortable death.
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6
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Flowers CR. Sequencing therapy in relapsed DLBCL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:146-154. [PMID: 36485076 PMCID: PMC9820056 DOI: 10.1182/hematology.2022000332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy worldwide, comprising approximately 30% of all lymphomas. Currently, 50% to 60% of patients diagnosed with DLBCL are alive at 5 years and cured with modern therapy, but about 10% to 15% of patients are refractory to first-line therapy, and an additional 20% to 30% relapse following a complete response. Patients who have relapses beyond 2 years may experience more favorable outcomes and have forms of DLBCL that can be distinguished biologically. Patients who experience early relapse or who have primary refractory disease (less than a complete response or relapse within 3 to 6 months of initial therapy) have worse outcomes. For decades, the standard of care treatment strategy for fit patients with relapsed DLBCL has been salvage therapy with non-cross-resistant combination chemoimmunotherapy regimens followed by high-dose chemotherapy and autologous stem cell transplantation (ASCT) as stem cell rescue for patients with chemosensitive disease. Recent data suggest that certain patients may benefit from chimeric antigen receptor T-cell therapy (CAR T) in the second-line setting. Additional novel therapies exist for patients who are ineligible, who are unable to access these therapies, or who fail ASCT and/or CAR T. Despite the advent of new therapies for DLBCL and improved outcomes, DLBCL remains a life-threatening illness. Thus, it is essential for clinicians to engage in serious illness conversations with their patients. Goals-of-care communication can be improved through skills-based training and has been demonstrated to have an impact on patient experiences.
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Affiliation(s)
- Christopher R. Flowers
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Shaulov A, Aviv A, Alcalde J, Zimmermann C. Early integration of palliative care for patients with haematological malignancies. Br J Haematol 2022; 199:14-30. [PMID: 35670630 PMCID: PMC9796711 DOI: 10.1111/bjh.18286] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/30/2022] [Accepted: 05/17/2022] [Indexed: 01/07/2023]
Abstract
Early palliative care (EPC) significantly improves quality of life, symptoms, and satisfaction with care for patients with advanced cancer. International organizations have recognized and promoted the role of palliative care as a distinct specialty, advocating its involvement throughout the cancer trajectory. Although patients with haematologic malignancies (HMs) have a comparable symptom burden to patients with solid tumours, they face multiple barriers to EPC integration. In this review, we discuss these barriers, present updated evidence from clinical trials of EPC in HMs and propose models to support EPC integration into care for patients with HMs.
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Affiliation(s)
- Adir Shaulov
- Department of HaematologyHadassah Medical CenterJerusalemIsrael,Faculty of MedicineHebrew University of JerusalemIsrael
| | - Ariel Aviv
- Department of HaematologyHaEmek Medical CenterAfulaIsrael
| | - Jacqueline Alcalde
- Department of Supportive Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada,Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
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8
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Ferraz LFDM, Ferreira APS, Guimarães TVV, de Melo Campos P. Early integration of palliative care in hematology: an urgency for patients, a challenge for physicians. Hematol Transfus Cell Ther 2022; 44:567-573. [PMID: 35989250 PMCID: PMC9605907 DOI: 10.1016/j.htct.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/11/2022] [Accepted: 06/24/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Objective and method Results and conclusion
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9
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Pitfalls and Successes in Trials in Older Transplant Patients with Hematologic Malignancies. Curr Oncol Rep 2022; 24:125-133. [DOI: 10.1007/s11912-022-01194-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/03/2022]
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10
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Pelcovits A, Olszewski AJ, Decker D, Guyer D, Leblanc TW, Egan P. Impact of Early Palliative Care on End-of-Life Outcomes in Hematologic Malignancies. J Palliat Med 2021; 25:556-561. [PMID: 34842462 DOI: 10.1089/jpm.2021.0193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Patients with hematologic malignancies (HMs) receive more disease directed care at the end of life (EOL) and often die in the hospital. The impact of early palliative care (PC) consultation on EOL quality outcomes in HMs has not been well described. Objectives: In 2017 we embedded a PC specialist within our inpatient malignant hematology team at our hospital in Providence, Rhode Island to facilitate the use of early PC. We sought to determine if this practice was accompanied by a shift in EOL outcomes. Design/Setting: We conducted a retrospective review of patients diagnosed with acute myeloid leukemia (AML) at our institution in the two years before (Cohort A) and after (Cohort B) insertion of a PC specialist. We identified patients who received a PC consultation and whether it was early or late. We then examined EOL quality outcomes: hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, chemotherapy use in the last 14 days of life, use of hospice, and death out of hospital. Results: Among 139 AML patients, 46 in Cohort A and 93 in Cohort B, we identified 34 and 47 decedents in each cohort, respectively. There was no significant improvement in EOL outcomes between Cohort A and B or among patients receiving early PC (p > 0.05); however, PC in general across all cohorts was associated with significant increase in hospice use and fewer ICU admissions (p = 0.016 and 0.0043, respectively). Conclusion: Earlier PC consultation in AML was not significantly associated with improvement in EOL quality outcomes; however, PC use in general was with improvement in use of hospice and ICU utilization. Further studies are needed to more definitively examine the relationship between early PC and EOL outcomes in patients with HMs and to examine non EOL outcomes such as patient experience and quality-of-life measures.
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Affiliation(s)
- Ari Pelcovits
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adam J Olszewski
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | - Dana Guyer
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Geriatrics and Palliative Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Thomas W Leblanc
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina, USA
| | - Pamela Egan
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
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11
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Borregaard Myrhøj C, Novrup Clemmensen S, Sax Røgind S, Jarden M, Toudal Viftrup D. Serious illness conversations in patients with multiple myeloma and their family caregivers-A qualitative interview study. Eur J Cancer Care (Engl) 2021; 31:e13537. [PMID: 34734446 DOI: 10.1111/ecc.13537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/02/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients treated for multiple myeloma often suffer from anxiety and depression related to concerns about the future. This indicates a need for improvement of communication between patients and healthcare professionals within haematology. The aim of this study was to explore how patients with multiple myeloma and their caregivers experience serious illness conversation focusing on illness understanding, concerns, values, and wishes for the future. METHODS Phenomenological, semi-structured dyad interviews were carried out in patients with multiple myeloma (n = 12) and their caregivers (n = 11) 2-20 days after participation in one serious illness conversation. interpretive phenomenological analysis was used for analysing data. RESULTS Three themes emerged (1) transforming patient-caregiver communication, (2) redeeming communication, and (3) equality in communication in an unequal relation. Furthermore, time allocated for the conversation and preparatory materials for the conversations highly influenced outcome. CONCLUSION The findings suggest that serious illness conversation can help patients and family caregivers managing living life with multiple myeloma by increasing dyadic communication and strengthen their use of existential language together with healthcare professionals. This study highlights the benefits of preparing patients and caregivers prior to the conversation and cancer care systems should strive to allocate ample time for serious illness conversations.
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Affiliation(s)
| | - Stine Novrup Clemmensen
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Signe Sax Røgind
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mary Jarden
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorte Toudal Viftrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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12
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Davis ES, Martinez I, Hurst G, Bhatia S, Johnston EE. Early palliative care is associated with less intense care in children dying with cancer in Alabama: A retrospective, single-site study. Cancer 2021; 128:391-400. [PMID: 34614197 DOI: 10.1002/cncr.33935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 08/11/2021] [Accepted: 08/30/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Regional studies show that children with cancer receive medically intense end-of-life (EOL) care, but EOL care patterns, including palliative care utilization in Alabama, remain unknown. METHODS This was a retrospective study of 233 children (0-19 years) who received cancer-directed therapy at Children's of Alabama and died from 2010 through 2019. Rates and disparities in palliative care utilization and the association between palliative care and intense EOL care, death location, and hospice were examined. RESULTS The median death age was 11 years; 62% were non-Hispanic White. Forty-one percent had a non-central nervous system (CNS) solid tumor. Fifty-eight percent received palliative care, and 36% received early palliative care (≥30 days before death). Children without relapsed/refractory disease were less likely to receive palliative care than those who had relapsed/refractory disease (adjusted odds ratio [aOR], 0.2; 95% confidence interval [CI], 0.1-0.7). Children with CNS tumors and hematologic malignancies were less likely to have early palliative care (aOR for CNS tumors, 0.4; 95% CI, 0.2-0.7; aOR for hematologic malignancies, 0.3; 95% CI, 0.2-0.7) than children with non-CNS solid tumors. Late palliative care (vs none) was associated with more medically intense care (aOR, 3.3; 95% CI, 1.4-7.8) and hospital death (aOR, 4.8; 95% CI, 1.9-11.6). Early palliative care (vs none) was associated with more hospice enrollment (aOR, 3.4; 95% CI, 1.5-7.6) but not medically intense care (aOR, 1.3; 95% CI, 0.6-2.9) or hospital death (aOR, 1.8; 95% CI, 0.8-3.7). CONCLUSIONS Fifty-eight percent of children dying of cancer in Alabama receive palliative care, but EOL care varies with the receipt and timing (early vs late) of palliative care. Whether this variation reflects differences in child and family preferences or systemic factors (eg, hospice access) remains unknown.
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Affiliation(s)
- Elizabeth S Davis
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Isaac Martinez
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Garrett Hurst
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily E Johnston
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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13
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Garraud O. Transfusion at the border of the "intention-to-treat", in the very aged person and in palliative care: A debate. Transfus Clin Biol 2021; 28:367-369. [PMID: 34464710 DOI: 10.1016/j.tracli.2021.08.350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022]
Abstract
In both palliative care and in the very aged person i.e. at the end of life, transfusion aims at bringing supportive care; it has indeed no intention to treat. It can occasionally be compassionate as to bring oxygen to a patient or a resident in nursing home wishing to enjoy some exercise or entertainment. Transfusion in this condition is not consensual, for reasons that are medical and/or societal. The present essay aims at discussing the main options to provide transfusion in such extreme, though non-exceptional, conditions.
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Affiliation(s)
- O Garraud
- INSERM_U1059, Faculty of medicine of Saint-Etienne, University of Lyon, Saint-Étienne, France.
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14
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Perspectives on Advance Care Planning for Patients with Hematologic Malignancy: An International Clinician Questionnaire. Ann Am Thorac Soc 2021; 18:1533-1539. [PMID: 33400904 DOI: 10.1513/annalsats.202006-678oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rationale: Critical illness is common in patients with hematologic malignancy (HM). Advance care planning (ACP) can allow these patients to express their care preferences before life-threatening illnesses. Objectives: To evaluate physicians' perspectives surrounding ACP in patients with HM. Methods: We administered a survey to intensivists and hematologic oncologists who care for patients with HM across Canada and the United Kingdom. Potential respondents were identified from institutions that have a hematologic-oncology program. The survey was disseminated electronically. Results: A total of 111 physicians completed the survey, with a response rate of 19% (39% across those who opened the e-mail); 52% of respondents were intensivists, and 48% of respondents were hematologic oncologists. Of the responses, 15.5% of physicians reported that ACP happens routinely at their institution, whereas 8.3% of physicians stated that code status is routinely discussed. ACP discussions were most commonly reported at the onset of critical illness (84.3% of respondents), during disease recurrence (52.9% of respondents), or during the transition to a strictly palliative approach (54.9% of respondents). Commonly cited barriers to ACP centered on physicians' concern about the reaction of the patient or family. Conclusions: This study emphasizes the need for earlier and more frequent ACP discussions in this high-risk population with a variety of barriers identified.
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15
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Polomeni A, Prod'homme C, Ainaoui M, Bellec A, Berr A, Bonneau J, Charbonnier A, Coiteux V, de Berranger E, Descamps T, Gire M, Goncalves M, Ruscassié A, Yakoub-Agha I, Borel C. [Palliative care in hematopoietic stem-cell transplanted patients: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2021; 108:S1-S9. [PMID: 34176584 DOI: 10.1016/j.bulcan.2021.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/17/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT), the only curative therapy for numerous hematological malignancies, carries a significant risk of morbidity and mortality. The patients and families' expectations regarding the procedure, the prognosis uncertainties, as well as the existence of potential new therapeutic possibilities, lead to frequent use of intensive care. Even though the transplant physicians are highly skilled in acute care, their knowledge of palliative approach is limited, making the use of palliative care insufficient and often late. By promoting reflection on the proportionality of care and the patients' quality of life, palliative care may contribute to the allo-HCT patients management. Nevertheless, obstacles to this approach remain. The objective of this work is to propose recommendations to promote the implementation of palliative care into transplant units.
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Affiliation(s)
- Alice Polomeni
- AP-HP, hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du Faubourg Saint-Antoine, 75011 Paris, France.
| | - Chloé Prod'homme
- CHRU de Lille, clinique de médecine palliative, hôpital Calmette, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - Malika Ainaoui
- CHRU de Lille, service des maladies du sang, avenue Michel-Polonovski, 59037 Lille cedex, France
| | - Adeline Bellec
- CHU de Rennes, service d'hématologie clinique, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France
| | - Aurélie Berr
- Institut de cancérologie Strasbourg Europe, service d'hématologie, 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg cedex, France
| | - Jacinthe Bonneau
- CHU de Rennes, hôpital Sud, service d'hématologie oncologie et greffe de moelle pédiatrique, 16, boulevard de Bulgarie, 35203 Rennes cedex 2, France
| | - Amandine Charbonnier
- CHU-groupe hospitalier Amiens-Sud, service d'hématologie clinique et thérapie cellulaire, 90054 Amiens cedex 1, France
| | - Valérie Coiteux
- CHRU de Lille, service des maladies du sang, avenue Michel-Polonovski, 59037 Lille cedex, France
| | - Eva de Berranger
- CHRU de Lille, hôpital Jeanne de Flandres, hématologie pédiatrique, avenue Eugène Avinée, 59037 Lille cedex, France
| | - Thomas Descamps
- CHRU de Lille, service des maladies du sang, avenue Michel-Polonovski, 59037 Lille cedex, France
| | - Marion Gire
- Institut de cancérologie Lucien Neuwirth, service d'hématologie, 104, avenue Albert-Raymond, 42270 Saint-Priest-en-Jarez, France
| | - Murielle Goncalves
- A.P.H.P., hôpital Saint-Antoine, service d'hématologie clinique et thérapie cellulaire, 184, rue du Faubourg Saint-Antoine, 75011 Paris, France
| | - Agnès Ruscassié
- Institut universitaire du cancer de Toulouse, département des soins de support, 1, avenue Irène Joliot-Curie, 31059 Toulouse cedex, France
| | | | - Cécile Borel
- Institut universitaire du cancer de Toulouse, service d'hématologie, 1, avenue Irène Joliot-Curie, 31059 Toulouse cedex, France
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Kuczmarski TM, Odejide OO. Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close? Curr Hematol Malig Rep 2021; 16:117-125. [PMID: 33864180 DOI: 10.1007/s11899-021-00629-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death. RECENT FINDINGS Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.
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Affiliation(s)
- Thomas M Kuczmarski
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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17
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Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplantation Recipients. Transplant Cell Ther 2021; 27:615.e1-615.e7. [PMID: 33836311 DOI: 10.1016/j.jtct.2021.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/19/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022]
Abstract
Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing the AD completion rate can improve the quality of care for allogeneic HCT recipients. Our objective was to evaluate whether an alternative AD instrument can increase AD completion rate and patient satisfaction. We conducted a prospective, randomized controlled study of the traditional California AD versus a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients age ≥18 years undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were assigned at random to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion. The chi-square test was used to compare the AD completion rate between arms. The Wilcoxon rank-sum test was used to compare uncertainty, satisfaction with decision making, and satisfaction with the AD. Of the 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years, 57 (45.2%) were female, and 74 (58.7%) were non-Hispanic white. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% versus 72.6%; P = .78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. In the traditional AD arm, 60.0% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional AD and Letter AD. Completion rates of AD on this study were high (71.4%) compared with historically reported completion rates and did not significantly differ based on AD version.
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18
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Rao VB, Belanger E, Egan PC, LeBlanc TW, Olszewski AJ. Early Palliative Care Services and End-of-Life Care in Medicare Beneficiaries with Hematologic Malignancies: A Population-Based Retrospective Cohort Study. J Palliat Med 2021; 24:63-70. [PMID: 32609039 PMCID: PMC8020510 DOI: 10.1089/jpm.2020.0006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 01/07/2023] Open
Abstract
Background: Patients with hematologic malignancies (HM) often receive aggressive care at the end of life (EOL). Early palliative care (PC) has been shown to improve EOL care outcomes, but its benefits are less established in HM than in solid tumors. Objectives: We sought to describe the use of billed PC services among Medicare beneficiaries with HM. We hypothesized that receipt of early PC services (rendered >30 days before death) may be associated with less aggressive EOL care. Design: Retrospective cohort analysis Setting/Subjects: Using the Surveillance, Epidemiology, and End Results-Medicare registry, we studied patients with leukemia, lymphoma, myeloma, myelodysplastic syndrome, or myeloproliferative neoplasm who died between 2001 and 2015. Measurements: We described trends in the use of PC services and evaluated the association between early PC services and metrics of EOL care aggressiveness. Results: Among 139,191 decedents, the proportion receiving PC services increased from 0.4% in 2001 to 13.3% in 2015. Median time from first encounter to death was 10 days and 84.3% of encounters occurred during hospitalizations. In patients who survived >30 days from diagnosis (N = 120,741), the use of early PC services was more frequent in acute leukemia, women, and black patients, among other characteristics. Early PC services were associated with increased hospice use and decreased health care utilization at the EOL. Conclusion: Among patients with HM, there was an upward trend in PC services, and early PC services were associated with less aggressive EOL care. Our results support the need for prospective trials of early PC in HM.
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Affiliation(s)
- Vinay B. Rao
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Pamela C. Egan
- Division of Hematology/Oncology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Thomas W. LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina, USA
| | - Adam J. Olszewski
- Division of Hematology/Oncology, Brown University, Providence, Rhode Island, USA
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Odejide OO. Strategies for introducing palliative care in the management of relapsed or refractory aggressive lymphomas. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:148-153. [PMID: 33275720 PMCID: PMC7727542 DOI: 10.1182/hematology.2020000100] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Recent advances in treatment of patients with aggressive lymphomas ranging from chimeric antigen receptor T-cell therapy to combination of antibody-drug conjugates with chemotherapy have improved survival outcomes. Despite these significant advances, patients with relapsed or refractory disease experience high physical and psychological symptom burden, and a substantial proportion still die of their lymphoma. In addition, end-of-life care outcomes are suboptimal with high rates of intensive end-of-life health care use and low rates of timely hospice enrollment. Integrating palliative care concurrently with disease-directed care for this patient population has strong potential to improve their symptom burden, quality of life, and end-of-life care. Multiple factors, including heightened prognostic uncertainty in the setting of relapsed/refractory disease, pose challenges to timely provision of palliative care. This article reviews benefits of primary and specialty palliative care for patients with relapsed/refractory aggressive lymphomas and barriers to such care. It also highlights strategies for effectively integrating palliative care for patients with relapsed/refractory aggressive lymphomas.
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Affiliation(s)
- Oreofe O Odejide
- Dana-Farber Cancer Institute, Boston, MA; and Harvard Medical School, Boston, MA
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20
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Dowling M, Fahy P, Houghton C, Smalle M. A qualitative evidence synthesis of healthcare professionals' experiences and views of palliative care for patients with a haematological malignancy. Eur J Cancer Care (Engl) 2020; 29. [PMID: 32902114 PMCID: PMC7757223 DOI: 10.1111/ecc.13316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/30/2020] [Accepted: 08/07/2020] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Maura Dowling
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Paul Fahy
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Mike Smalle
- James Hardiman Library, National University of Ireland, Galway, Ireland
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21
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Freeman CL, Mikhael J. COVID-19 and myeloma: what are the implications for now and in the future? Br J Haematol 2020; 190:173-178. [PMID: 32428242 PMCID: PMC7276733 DOI: 10.1111/bjh.16815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/12/2020] [Indexed: 12/14/2022]
Abstract
The pandemic has affected every aspect of myeloma care. Immediate focus is minimising risk of contracting coronavirus disease 2019 (COVID-19) and the sequelae of infection. However, what does the future hold for our patients? What lessons will be taken forward to tackle myeloma in the fiscally constrained future? If we embrace the challenges that will emerge in the post-pandemic environment, the treatment delivered to patients could be more cost-effective and better tailored than before. Healthcare delivery post-COVID-19 will not return to how it was, and now is the time to invest in novel strategies to deliver the best possible outcomes for patients.
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Affiliation(s)
- Ciara L Freeman
- Centre for Lymphoid Cancer and Division of Medical Oncology, BC Cancer and the University of British Columbia, Vancouver, BC, Canada
| | - Joseph Mikhael
- Applied Cancer Research and Drug Discovery, Translational Genomics Research Institute, City of Hope Cancer Center, Duarte, CA, USA
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22
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Henckel C, Revette A, Huntington SF, Tulsky JA, Abel GA, Odejide OO. Perspectives Regarding Hospice Services and Transfusion Access: Focus Groups With Blood Cancer Patients and Bereaved Caregivers. J Pain Symptom Manage 2020; 59:1195-1203.e4. [PMID: 31926969 PMCID: PMC7239741 DOI: 10.1016/j.jpainsymman.2019.12.373] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Patients with blood cancers have low rates of timely hospice use. Barriers to hospice use for this population are not well understood. Lack of transfusion access in most hospice settings is posited as a potential reason for low and late enrollment rates. OBJECTIVES We explored the perspectives of patients with blood cancers and their bereaved caregivers regarding the value of hospice services and transfusions. METHODS Between June 2018 and January 2019, we conducted three focus groups with blood cancer patients with an estimated life expectancy of six months or less and two focus groups with bereaved caregivers of patients with blood cancers. We asked participants their perspectives regarding quality of life (QOL) and about the potential association of traditional hospice services and transfusions with QOL. A hematologic oncologist, sociologist, and qualitatively trained research assistant conducted thematic analysis of the data. RESULTS Twenty-seven individuals (18 patients and nine bereaved caregivers) participated in the five focus groups. Participants identified various QOL domains that were important to them but focused largely on a desire for energy to maintain physical/functional well-being. Participants considered transfusions a high-priority service for their QOL. They also felt that standard hospice services were important for QOL. Bereaved caregivers reported overall positive experiences with hospice. CONCLUSION Our analysis suggests that although patients with blood cancers value hospice services, they also consider transfusions vital to their QOL. Innovative care delivery models that combine the elements of standard hospice services with other patient-valued services like transfusions are most likely to optimize end-of-life care for patients with blood cancers.
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Affiliation(s)
| | - Anna Revette
- Dana-Farber/Harvard Cancer Center Survey and Data Management Core, Boston, Massachusetts, USA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory A Abel
- Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Oreofe O Odejide
- Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
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23
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Odejide OO, Steensma DP. Patients with haematological malignancies should not have to choose between transfusions and hospice care. LANCET HAEMATOLOGY 2020; 7:e418-e424. [PMID: 32359453 DOI: 10.1016/s2352-3026(20)30042-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/11/2022]
Abstract
Hospice programmes are important for providing end-of-life care to patients with life-limiting illnesses. Hospice enrolment improves quality of life for patients with advanced cancer and reduces the risk of depression for caregivers. Despite the clear benefits of hospice care, patients with haematological malignancies have the lowest rates of enrolment among patients with any tumour subtype. Furthermore, when patients with haematological disorders do enrol into hospice care, they are more likely to do so within 3 days of death than are patients with non-haematological malignancies. Although reasons for low and late hospice use in this population are multifactorial, a key barrier is limited access to blood transfusions in hospice programmes. In this Viewpoint, we discuss the relationship between transfusion dependence and hospice use for patients with blood cancers. We suggest that rather than constraining patients into either transfusion or hospice models, policies that promote combining palliative transfusions with hospice services are likely to optimise end-of-life care for patients with haematological malignancies.
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Affiliation(s)
- Oreofe O Odejide
- Harvard Medical School, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - David P Steensma
- Harvard Medical School, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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24
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Tanzi S, Luminari S, Cavuto S, Turola E, Ghirotto L, Costantini M. Early palliative care versus standard care in haematologic cancer patients at their last active treatment: study protocol of a feasibility trial. BMC Palliat Care 2020; 19:53. [PMID: 32321483 PMCID: PMC7178743 DOI: 10.1186/s12904-020-00561-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 04/13/2020] [Indexed: 01/03/2023] Open
Abstract
Background Patients with advanced haematological malignancies suffer from a very high symptom burden and psychological, spiritual, social and physical symptoms comparable with patients with metastatic non-haematological malignancy. Referral to palliative care services for these patients remains limited or often confined to the last days of life. We developed a palliative care intervention (PCI) integrated with standard haematological care. The aim of the study was focussed on exploring the feasibility of the intervention by patients, professionals and caregivers and on assessing its preliminary efficacy. Methods/design. This is a mixed-methods phase 2 trial. The Specialist Palliative Care Team (SPCT) will follow each patient on a monthly basis in the outpatient clinic or will provide consultations during any hospital admission. SPCT and haematologists will discuss active patient issues to assure a team approach to the patient’s care. This quantitative study is a monocentric parallel-group superiority trial with balanced randomisation comparing the experimental PCI plus haematological standard care versus haematological standard care alone. The primary endpoint will calculate on adherence to the planned PCI, measured as the percentage of patients randomised to the experimental arm who attend all the planned palliative care visits in the 24 weeks after randomisation. The qualitative study follows the methodological indications of concurrent nested design and was aimed at exploring the acceptability of the PCI from the point of view of patients, caregivers and physicians. Discussion In this trial, we will test the feasibility of an integrated palliative care approach starting when the haematologist decides to propose the last active treatment to the patient, according to his/her clinical judgement. We decided to test this criterion because it is able to intercept a wide range of patients’needs. The feasibility of this approach requires that we enrol at least 60 patients and that more than 50% of them be followed by the palliative care team for at least 24 weeks. The trial will include integrated qualitative data analysis; to give essential information on feasibility and acceptability. Trial registration ClinicalTrials.gov: NCT03743480 (November 16, 2018).
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Affiliation(s)
- Silvia Tanzi
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy. .,Clinical and Experimental Medicine PhD program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Stefano Luminari
- Haematology Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvio Cavuto
- Clinical Trials an Statistics Unit, Infrastructure Research and Statistic, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elena Turola
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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25
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El-Jawahri A, Nelson AM, Gray TF, Lee SJ, LeBlanc TW. Palliative and End-of-Life Care for Patients With Hematologic Malignancies. J Clin Oncol 2020; 38:944-953. [PMID: 32023164 PMCID: PMC8462532 DOI: 10.1200/jco.18.02386] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2019] [Indexed: 12/18/2022] Open
Abstract
Hematologic malignancies are a heterogeneous group of diseases with unique illness trajectories, treatment paradigms, and potential for curability, which affect patients' palliative and end-of-life care needs. Patients with hematologic malignancies endure immense physical and psychological symptoms because of both their illness and often intensive treatments that result in significant toxicities and adverse effects. Compared with patients with solid tumors, those with hematologic malignancies also experience high rates of hospitalizations, intensive care unit admissions, and in-hospital deaths and low rates of referral to hospice as well as shorter hospice length of stay. In addition, patients with hematologic malignancies harbor substantial misperceptions about treatment risks and benefits and frequently overestimate their prognosis. Even survivors of hematologic malignancies struggle with late effects, post-treatment complications, and post-traumatic stress symptoms that can significantly diminish their quality of life. Despite these substantial unmet needs, specialty palliative care services are infrequently consulted for the care of patients with hematologic malignancies. Several illness-specific, cultural, and system-based barriers to palliative care integration and optimal end-of-life care exist in this population. However, recent evidence has demonstrated the feasibility, acceptability, and efficacy of integrating palliative care to improve the quality of life and care of patients with hematologic malignancies and their caregivers. More research is needed to develop and test population-specific palliative and supportive care interventions to ensure generalizability and to define a sustainable clinical delivery model. Future work also should focus on identifying moderators and mediators of the effect of integrated palliative care models on patient-reported outcomes and on developing less resource-intensive integrated care models to address the diverse needs of this population.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ashley M. Nelson
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Tamryn F. Gray
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
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26
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Ufere NN, Donlan J, Waldman L, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer JA, Temel JS, Chung RT, El-Jawahri A. Barriers to Use of Palliative Care and Advance Care Planning Discussions for Patients With End-Stage Liver Disease. Clin Gastroenterol Hepatol 2019; 17:2592-2599. [PMID: 30885884 PMCID: PMC6745282 DOI: 10.1016/j.cgh.2019.03.022] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/28/2019] [Accepted: 03/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Despite evidence for the benefits of palliative care (PC) referrals and early advance care planning (ACP) discussions for patients with chronic diseases, patients with end-stage liver disease (ESLD) often do not receive such care. We sought to examine physicians' perceptions of the barriers to PC and timely ACP discussions for patients with ESLD. METHODS We conducted a cross-sectional survey of hepatologists and gastroenterologists who provide care to adult patients with ESLD, recruited from the American Association for the Study of Liver Diseases 2018 membership registry. Using a questionnaire adapted from prior studies, we assessed physicians' perceptions of barriers to PC use and timely ACP discussions; 396 of 1236 eligible physicians (32%) completed the questionnaire. RESULTS The most commonly cited barriers to PC use were cultural factors that affect perception of PC (by 95% of respondents), unrealistic expectations from patients about their prognosis (by 93% of respondents), and competing demands for clinicians' time (by 91% of respondents). Most respondents (81%) thought that ACP discussions with patients who have ESLD typically occur too late in the course of illness. The most commonly cited barriers to timely ACP discussions were insufficient communication between clinicians and families about goals of care (by 84% of respondents) and insufficient cultural competency training about end-of-life care (81%). CONCLUSION There are substantial barriers to use of PC and timely discussions about ACP-most hepatologists and gastroenterologists believe that ACP occurs too late for patients with ESLD. Strategies are needed to overcome barriers and increase delivery of high-quality palliative and end-of-life care to patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph A. Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer S. Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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Odejide OO, Uno H, Murillo A, Tulsky JA, Abel GA. Goals of care discussions for patients with blood cancers: Association of person, place, and time with end-of-life care utilization. Cancer 2019; 126:515-522. [PMID: 31593321 DOI: 10.1002/cncr.32549] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/04/2019] [Accepted: 08/28/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with blood cancers experience high-intensity medical care near the end of life (EOL) and low rates of hospice use; attributes of goals of care (GOC) discussions may partly explain these outcomes. METHODS By using a retrospective cohort of patients with blood cancer who received care at Dana-Farber Cancer Institute and died in 2014, the authors assessed the potential relationship between timing, location, and the involvement of hematologic oncologists in the first GOC discussion with intensity of care near the EOL and timely hospice use. RESULTS Among 383 patients, 39.2% had leukemia/myelodysplastic syndromes, 37.1% had lymphoma, and 23.7% had myeloma. Overall, 65.3% of patients had a documented GOC discussion. Of the first discussions, 33.2% occurred >30 days before death, 34.8% occurred in the outpatient setting, and 46.4% included a hematologic oncologist. In multivariable analyses, having the first discussion >30 days before death (odds ratio [OR], 0.37; 95% CI, 0.17-0.81), in the outpatient setting (OR, 0.21; 95% CI, 0.09-0.50), and having a hematologic oncologist present (OR, 0.40; 95% CI, 0.21-0.77) were associated with lower odds of intensive care unit admission ≤30 days before death. The presence of a hematologic oncologist at the first discussion (OR, 3.07; 95% CI, 1.58-5.96) also was associated with earlier hospice use (>3 days before death). CONCLUSIONS In this large cohort of blood cancer decedents, most initial GOC discussions occurred close to death and in the inpatient setting. When discussions were timely, outpatient, or involved hematologic oncologists, patients were less likely to experience intensive health care use near death and were more likely to enroll in hospice.
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Affiliation(s)
- Oreofe O Odejide
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Center for Lymphoma, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hajime Uno
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anays Murillo
- Tufts University School of Medicine, Boston, Massachusetts
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory A Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Center for Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Cost differential associated with hospice use among older patients with multiple myeloma. J Geriatr Oncol 2019; 11:88-92. [PMID: 31262592 DOI: 10.1016/j.jgo.2019.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/10/2019] [Accepted: 06/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospice is an effective end-of-life care approach for patients with incurable illnesses such as multiple myeloma; however, it has been historically underutilized. In addition to improving quality of life, hospice enrollment reduces healthcare spending in many incurable illnesses but this has been unstudied in the myeloma population to date. MATERIAL AND METHODS Retrospective analysis of myeloma cases diagnosed from 2007 to 2013 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset. Included patients were: diagnosed at age 65 or older, received myeloma-directed therapy, had an overall survival >3 months, and were enrolled in Medicare the month preceding death. Costs included those paid by Medicare and patient copays during the 30 days preceding death. RESULTS 2075 patients were included in the analysis. 56% were enrolled in hospice at end of life. Increasing age and female gender were associated with greater odds of hospice enrollment. Non-white race, Medicaid enrollment, and increasing comorbidities were associated with decreased odds. Hospice enrollment was associated with a $13,574 (p < .0001) decrease in costs; however, the maximal savings were observed by those enrolled >14 days prior to death. CONCLUSION While improving quality of life should be the ultimate reason for increasing hospice utilization among patients with myeloma, there seems to be considerable cost implications as well.
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Ufere NN, Donlan J, Waldman L, Patel A, Dienstag JL, Friedman LS, Corey KE, Hashemi N, Carolan P, Mullen AC, Thiim M, Bhan I, Nipp R, Greer J, Temel J, Chung RT, El-Jawahri A. Physicians' Perspectives on Palliative Care for Patients With End-Stage Liver Disease: A National Survey Study. Liver Transpl 2019; 25:859-869. [PMID: 30963669 PMCID: PMC6529275 DOI: 10.1002/lt.25469] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/24/2019] [Indexed: 12/12/2022]
Abstract
Specialty palliative care (PC) is underused for patients with end-stage liver disease (ESLD). We sought to examine attitudes of hepatologists and gastroenterologists about PC for patients with ESLD. We conducted a cross-sectional survey of these specialists who provide care to patients with ESLD. Participants were recruited from the American Association for the Study of Liver Diseases membership directory. Using a questionnaire adapted from prior studies, we examined physicians' attitudes about PC and whether these attitudes varied based on patients' candidacy for liver transplantation. We identified predictors of physicians' attitudes about PC using linear regression. Approximately one-third of eligible physicians (396/1236, 32%) completed the survey. Most (95%) believed that centers providing care to patients with ESLD should have PC services, and 86% trusted PC clinicians to care for their patients. Only a minority reported collaborating frequently with inpatient (32%) or outpatient (11%) PC services. Most believed that when patients hear the term PC, they feel scared (94%) and anxious (87%). Most (83%) believed that patients would think nothing more could be done for their underlying disease if a PC referral was suggested. Physicians who believed that ESLD is a terminal condition (B = 1.09; P = 0.006) reported more positive attitudes about PC. Conversely, physicians with negative perceptions of PC for transplant candidates (B = -0.22; standard error = 0.05; P < 0.001) reported more negative attitudes toward PC. In conclusion, although most hepatologists and gastroenterologists believe that patients with ESLD should have access to PC, they reported rarely collaborating with PC teams and had substantial concerns about patients' perceptions of PC. Interventions are needed to overcome misperceptions of PC and to promote collaboration with PC clinicians for patients with ESLD.
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Affiliation(s)
- Nneka N. Ufere
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - John Donlan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Lauren Waldman
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Arpan Patel
- Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jules L. Dienstag
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | | | - Kathleen E. Corey
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Nikroo Hashemi
- Division of Gastroenterology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, USA
| | - Peter Carolan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Alan C. Mullen
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Michael Thiim
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Irun Bhan
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Ryan Nipp
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Joseph Greer
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Jennifer Temel
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond T. Chung
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
| | - Areej El-Jawahri
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
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Elias R, Odejide O. Immunotherapy in Older Adults: A Checkpoint to Palliation? Am Soc Clin Oncol Educ Book 2019; 39:e110-e120. [PMID: 31099630 DOI: 10.1200/edbk_238795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The excitement about immunotherapy is justified. Patients with advanced disease and limited life expectancy before immune checkpoint inhibitors are now having prolonged and sometimes complete responses to treatment; however, most patients do not respond to checkpoint inhibitors. The hope for a meaningful response with only a limited risk of high-grade toxicity generated a prognostic dilemma for patients with advanced cancers and their treating oncologists. Older adults with advanced cancers are at the intersection of multiple biologic and clinical factors that can influence the efficacy of immunotherapy. Treating physicians should take all of these elements into account when considering treatment options for an older adult with advanced disease. Oncologists should have an honest conversation with their patients regarding the uncertainty around the clinical profile of checkpoint inhibitors. Early high-quality goals of care discussions can help manage expectations of older adults with advanced cancer treated with immunotherapy. We review in this paper select clinical characteristics that are important to consider when evaluating an older adult for checkpoint inhibitor therapy. In addition, we discuss strategies to optimize goals of care discussion given the increasing complexity of prognostication in the immunotherapy era.
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Affiliation(s)
- Rawad Elias
- 1 Hartford HealthCare Cancer Institute, Hartford Hospital, Hartford, CT
| | - Oreofe Odejide
- 2 Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Gerlach C, Goebel S, Weber S, Weber M, Sleeman KE. Space for intuition - the 'Surprise'-Question in haemato-oncology: Qualitative analysis of experiences and perceptions of haemato-oncologists. Palliat Med 2019; 33:531-540. [PMID: 30688151 DOI: 10.1177/0269216318824271] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Early integration of palliative care can improve outcomes for people with cancer and non-cancer diagnoses. However, prediction of survival for individuals is challenging, in particular in patients with haematological malignancies who are known to have limited access to palliative care. The 'Surprise'-Question can be used to facilitate referral to palliative care. AIM To explore experiences, views and perceptions of haemato-oncologists on the use of the 'Surprise'-Question in the haemato-oncology outpatients clinics of a university hospital in Germany. DESIGN A qualitative study using individual semi-structured interviews transcribed verbatim and analysed thematically based on the framework approach. SETTING/PARTICIPANTS The study took place at the haemato-oncology outpatient clinic and the bone marrow transplantation outpatient clinic of a university hospital. Nine haemato-oncologists participated in qualitative interviews. RESULTS Thematic analysis identified 4 themes and 11 subthemes: (1) meaning and relevance of the 'Surprise'-Question; (2) feasibility; (3) the concept of 'surprise' and (4) personal aspects of prognostication. A key function of the 'Surprise'-Question was to stimulate intuition and promote patient-centred goals of care by initiating a process of pause → reflection → change of perspective. It was easy and quick to use, but required time and communication skills to act on. Participants' training in palliative care enhanced their willingness to use the 'Surprise'-Question. CONCLUSION Irrespective of its use in prognostication, the 'Surprise'-Question is a valuable tool to facilitate consideration of patient-centred goals and promote holistic care in haemato-oncology. However, prognostic uncertainty, lack of time and communication skills are barriers for integration into daily practice. Further research should involve haematology patients to integrate their needs and preferences.
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Affiliation(s)
- Christina Gerlach
- 1 III. Department of Medicine, Interdisciplinary Department of Palliative Care, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Swantje Goebel
- 1 III. Department of Medicine, Interdisciplinary Department of Palliative Care, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Sascha Weber
- 1 III. Department of Medicine, Interdisciplinary Department of Palliative Care, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany.,2 Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Germany
| | - Martin Weber
- 1 III. Department of Medicine, Interdisciplinary Department of Palliative Care, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Katherine E Sleeman
- 3 King's College London, Cicely Saunders Institute, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, London, UK
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32
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Oechsle K. Palliative Care in Patients with Hematological Malignancies. Oncol Res Treat 2018; 42:25-30. [PMID: 30537761 DOI: 10.1159/000495424] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/14/2018] [Indexed: 12/22/2022]
Abstract
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.
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Johnston EE, Muffly L, Alvarez E, Saynina O, Sanders LM, Bhatia S, Chamberlain LJ. End-of-Life Care Intensity in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation: A Population-Level Analysis. J Clin Oncol 2018; 36:3023-3030. [PMID: 30183467 DOI: 10.1200/jco.2018.78.0957] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Intensity of end-of-life care receives much attention in oncology because of concerns that high-intensity care is inconsistent with patient goals, leads to worse caregiver outcomes, and is expensive. Little is known about such care in those undergoing allogeneic hematopoietic cell transplantation (HCT), a population at high risk for morbidity and mortality. PATIENTS AND METHODS We conducted a population-based analysis of patients who died between 2000 and 2013, within 1 year of undergoing an inpatient allogeneic HCT using California administrative data. Previously validated markers of intensity were examined and included: hospital death, intensive care unit (ICU) admission, and procedures such as intubation and cardiopulmonary resuscitation at end of life. Multivariable logistic regression models determined clinical and sociodemographic factors associated with: hospital death, a medically intense intervention (ICU admission, cardiopulmonary resuscitation, hemodialysis, intubation), and ≥ two intensity markers. RESULTS Of the 2,135 patients in the study population, 377 were pediatric patients (age ≤ 21 years), 461 were young adults (age 22 to 39 years), and 1,297 were adults (age ≥ 40 years). The most common intensity markers were: hospital death (83%), ICU admission (49%), and intubation (45%). Medical intensity varied according to age, underlying diagnosis, and presence of comorbidities at time of HCT. Patients with higher-intensity end-of-life care included patients age 15 to 21 years and 30 to 59 years, patients with acute lymphoblastic leukemia, and those with comorbidities at time of HCT. CONCLUSION Patients dying within 1 year of inpatient allogeneic HCT are receiving medically intense end-of-life care with variations related to age, underlying diagnosis, and presence of comorbidities at time of HCT. Future studies need to determine if these patterns are consistent with patient and family goals.
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Affiliation(s)
- Emily E Johnston
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Lori Muffly
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Elysia Alvarez
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Olga Saynina
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Lee M Sanders
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Smita Bhatia
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
| | - Lisa J Chamberlain
- Emily E. Johnston, Lori Muffly, Olga Saynina, Lee M. Sanders, and Lisa J. Chamberlain, Stanford University, Stanford; Elysia Alvarez, University of California Davis, Davis, CA; and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL
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Strand JJ, LeBlanc TW. Palliative care integration in haematological malignancies: towards a needs-based approach. BMJ Support Palliat Care 2018; 8:289-291. [DOI: 10.1136/bmjspcare-2018-001611] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/01/2018] [Indexed: 11/03/2022]
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Hudson KE, Wolf SP, Samsa GP, Kamal AH, Abernethy AP, LeBlanc TW. The Surprise Question and Identification of Palliative Care Needs among Hospitalized Patients with Advanced Hematologic or Solid Malignancies. J Palliat Med 2018; 21:789-795. [PMID: 29420142 DOI: 10.1089/jpm.2017.0509] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Little is known about quality of life (QOL), depression, and end-of-life (EOL) outcomes among hospitalized patients with advanced cancer. OBJECTIVE To assess whether the surprise question identifies inpatients with advanced cancer likely to have unmet palliative care needs. DESIGN Prospective cohort study and long-term follow-up. SETTING/SUBJECTS From 2008 to 2010, we enrolled 150 inpatients at Duke University with stage III/IV solid tumors or lymphoma/acute leukemia and whose physician would not be surprised if they died in less than one year. MEASUREMENTS We assessed QOL (FACT-G), mood (brief CES-D), and EOL outcomes. RESULTS Mean FACT-G score was quite low (66.9; SD 11). Forty-five patients (30%) had a brief CES-D score of ≥4 indicating a high likelihood of depression. In multivariate analyses, better QOL was associated with less depression (OR 0.91, p < 0.0001), controlling for tumor type, education, and spiritual well-being. Physicians correctly estimated death within one year in 101 (69%) cases, yet only 37 patients (25%) used hospice, and 4 (2.7%) received a palliative care consult; 89 (60.5%) had a do-not-resuscitate order, and 63 (43%) died in the hospital. CONCLUSIONS The surprise question identifies inpatients with advanced solid or hematologic cancers having poor QOL and frequent depressive symptoms. Although physicians expected death within a year, EOL quality outcomes were poor. Hospitalized patients with advanced cancer may benefit from palliative care interventions to improve mood, QOL, and EOL care, and the surprise question is a practical method to identify those with unmet needs.
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Affiliation(s)
| | - Steven Paul Wolf
- 2 Biostatistics Core, Duke University School of Medicine , Durham, North Carolina
| | - Gregory P Samsa
- 2 Biostatistics Core, Duke University School of Medicine , Durham, North Carolina
| | - Arif H Kamal
- 3 Duke Cancer Institute , Durham, North Carolina
| | - Amy Pickar Abernethy
- 4 Duke Clinical Research Institute , Durham, North Carolina
- 5 Flatiron Health , New York, New York
| | - Thomas William LeBlanc
- 3 Duke Cancer Institute , Durham, North Carolina
- 6 Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine , Durham, North Carolina
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Beaussant Y, Daguindau E, Chauchet A, Rochigneux P, Tournigand C, Aubry R, Morin L. Hospital end-of-life care in haematological malignancies. BMJ Support Palliat Care 2018; 8:314-324. [PMID: 29434048 DOI: 10.1136/bmjspcare-2017-001446] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate patterns of care during the last months of life of hospitalised patients who died from different haematological malignancies. METHODS Nationwide register-based study, including all hospitalised adults ≥20 years who died from haematological malignancies in France in 2010-2013. Outcomes included use of invasive cancer treatments and referral to palliative care. Percentages are adjusted for sex and age using direct standardisation. RESULTS Of 46 629 inpatients who died with haematological malignancies, 24.5% received chemotherapy during the last month before death, 48.5% received blood transfusion, 12.3% were under invasive ventilation and 18.1% died in intensive care units. We found important variations between haematological malignancies. The use of chemotherapy during the last month of life varied from 8.6% among patients with chronic myeloid leukaemia up to 30.1% among those with non-Hodgkin's lymphoma (P<0.001). Invasive ventilation was used in 10.2% of patients with acute leukaemia but in 19.0% of patients with Hodgkin's lymphoma (P<0.001). Palliative status was reported 30 days before death in only 14.8% of patients, and at time of death in 46.9% of cases. Overall, 5.5% of haematology patients died in palliative care units. CONCLUSION A high proportion of patients who died from haematological malignancies receive specific treatments near the end of life. There is a need for a better and earlier integration of the palliative care approach in the standard practice of haematology. However, substantial variation according to the type of haematological malignancy suggests that the patients should not be considered as one homogeneous group. Implementation of palliative care should account for differences across haematological malignancies.
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Affiliation(s)
- Yvan Beaussant
- Department of Palliative Care, Besancon University Hospital, Besançon, France.,Inserm CIT808, Besancon University Hospital, Besancon, France
| | - Etienne Daguindau
- Hematology Department, Besancon University Hospital, Besancon, France
| | - Adrien Chauchet
- Hematology Department, Besancon University Hospital, Besancon, France
| | - Philippe Rochigneux
- Department of Medical Oncology, Paoli-Calmettes Cancer Institute, Marseille, France
| | - Christophe Tournigand
- Department of Medical Oncology, Hopital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France.,Paris-Est Creteil University, Créteil, France
| | - Régis Aubry
- Department of Palliative Care, Besancon University Hospital, Besançon, France.,Inserm CIT808, Besancon University Hospital, Besancon, France
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
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Freeman AT, Wood WA, Fox A, Hanson LC. Access to Palliative Care Consultation and Advance Care Planning for Adults with High-Risk Leukemia. J Palliat Med 2017; 21:225-228. [PMID: 28795860 DOI: 10.1089/jpm.2017.0097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although strong evidence supports early palliative care (PC) and consistent advance care planning (ACP) for patients with poor-prognosis Stage IV solid tumors, best practice standards have not been established for hematologic malignancies. Our primary objective was to describe current access to specialty PC consultation and ACP for inpatients with high-risk leukemia. Secondary objectives were to describe components of ACP and PC practices. METHODS We enrolled all patients with high-risk leukemia (acute leukemia ≥65 years or relapsed leukemia >18 years) admitted to the University of North Carolina Cancer Hospital from October 1, 2015, to August 1, 2016. Structured chart reviews provided data on demographics, disease characteristics, PC consultation, frequency and components of documented ACP, and quality measures for PC practices. RESULTS Of 50 high-risk leukemia patients, 52% were 65 years of age or older with a new diagnosis of acute leukemia and 48% were under the age of 65 with relapsed leukemia. Most patients (64%) reported pain on admission. Twenty-two percent of patients died within 3 months of hospitalization. Sixteen percent of patients received PC consultation and 24% had complete ACP, with an identified surrogate decision-maker documented treatment preferences. CONCLUSIONS In this descriptive study of inpatients with high-risk leukemia, we found that despite a poor prognosis and high symptom burden, the frequency of PC consultation and ACP documentation was low. Findings suggest missed opportunities to provide PC to a high-risk subset of hematologic malignancies, and may help to target future interventions.
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Affiliation(s)
- Ashley T Freeman
- 1 Division of Hematology and Oncology, The University of North Carolina , Chapel Hill, North Carolina
| | - William A Wood
- 1 Division of Hematology and Oncology, The University of North Carolina , Chapel Hill, North Carolina
| | - Alexandra Fox
- 2 Palliative Care Program, Division of Geriatric Medicine, Center for Aging and Health, The University of North Carolina , Chapel Hill, North Carolina
| | - Laura C Hanson
- 2 Palliative Care Program, Division of Geriatric Medicine, Center for Aging and Health, The University of North Carolina , Chapel Hill, North Carolina
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Wang R, Zeidan AM, Halene S, Xu X, Davidoff AJ, Huntington SF, Podoltsev NA, Gross CP, Gore SD, Ma X. Health Care Use by Older Adults With Acute Myeloid Leukemia at the End of Life. J Clin Oncol 2017; 35:3417-3424. [PMID: 28783450 DOI: 10.1200/jco.2017.72.7149] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Little is known about the patterns and predictors of the use of end-of-life health care among patients with acute myeloid leukemia (AML). End-of-life care is particularly relevant for older adults with AML because of their poor prognosis. Methods We performed a population-based, retrospective cohort study of patients with AML who were ≥ 66 years of age at diagnosis and diagnosed during the period from 1999 to 2011 and died before December 31, 2012. Medicare claims were used to assess patterns of hospice care and use of aggressive treatment. Predictors of these end points were evaluated using multivariable logistic regression analyses. Results In the overall cohort (N = 13,156), hospice care after AML diagnosis increased from 31.3% in 1999 to 56.4% in 2012, but the increase was primarily driven by late hospice enrollment that occurred in the last 7 days of life. Among the 5,847 patients who enrolled in hospice, 47.4% and 28.8% started their first hospice enrollment in the last 7 and 3 days of life, respectively. Among patients who transferred in and out of hospice care, 62% received transfusions outside hospice. Additionally, the use of chemotherapy within the last 14 days of life increased from 7.7% in 1999 to 18.8% in 2012. Patients who were male and nonwhite were less likely to enroll in hospice and more likely to receive chemotherapy or be admitted to intensive care units at the end of life. Conversely, older patients were less likely to receive chemotherapy or have intensive care unit admission at the end of life, and were more likely to enroll in hospice. Conclusion End-of-life care for older patients with AML is suboptimal. Additional research is warranted to identify reasons for their low use of hospice services and strategies to enhance end-of-life care for these patients.
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Affiliation(s)
- Rong Wang
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Amer M Zeidan
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Stephanie Halene
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Xiao Xu
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Amy J Davidoff
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Scott F Huntington
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Nikolai A Podoltsev
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Cary P Gross
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Steven D Gore
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
| | - Xiaomei Ma
- Rong Wang, Amy J. Davidoff, and Xiaomei Ma, Yale School of Public Health; Rong Wang, Amer M. Zeidan, Xiao Xu, Amy J. Davidoff, Scott F. Huntington, Cary P. Gross, and Xiaomei Ma, Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center; Amer M. Zeidan, Stephanie Halene, Xiao Xu, Scott F. Huntington, Nikolai A. Podoltsev, Cary P. Gross, and Steven D. Gore, Yale School of Medicine, New Haven, CT
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McCaughan D, Roman E, Smith AG, Garry A, Johnson M, Patmore R, Howard M, Howell DA. Determinants of hospital death in haematological cancers: findings from a qualitative study. BMJ Support Palliat Care 2017; 8:78-86. [PMID: 28663341 PMCID: PMC5867428 DOI: 10.1136/bmjspcare-2016-001289] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/07/2017] [Accepted: 05/20/2017] [Indexed: 11/10/2022]
Abstract
Objectives Current UK health policy promotes enabling people to die in a place they choose, which for most is home. Despite this, patients with haematological malignancies (leukaemias, lymphomas and myeloma) are more likely to die in hospital than those with other cancers, and this is often considered a reflection of poor quality end-of-life care. This study aimed to explore the experiences of clinicians and relatives to determine why hospital deaths predominate in these diseases. Methods The study was set within the Haematological Malignancy Research Network (HMRN—www.hmrn.org), an ongoing population-based cohort that provides infrastructure for evidence-based research. Qualitative interviews were conducted with clinical staff in haematology, palliative care and general practice (n=45) and relatives of deceased HMRN patients (n=10). Data were analysed for thematic content and coding and classification was inductive. Interpretation involved seeking meaning, salience and connections within the data. Results Five themes were identified relating to: the characteristics and trajectory of haematological cancers, a mismatch between the expectations and reality of home death, preference for hospital death, barriers to home/hospice death and suggested changes to practice to support non-hospital death, when preferred. Conclusions Hospital deaths were largely determined by the characteristics of haematological malignancies, which included uncertain trajectories, indistinct transitions and difficulties predicting prognosis and identifying if or when to withdraw treatment. Advance planning (where possible) and better communication between primary and secondary care may facilitate non-hospital death.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Anne Garry
- Department of Palliative Care, York Hospital, York, UK
| | - Miriam Johnson
- Centre for Health and Population Sciences, University of Hull, Hull, UK
| | - Russell Patmore
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, UK
| | | | - Debra A Howell
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
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Wang WS, Ma JD, Nelson SH, Revta C, Buckholz GT, Mulroney CM, Roeland EJ. Advance Care Planning and Palliative Care Integration for Patients Undergoing Hematopoietic Stem-Cell Transplantation. J Oncol Pract 2017. [PMID: 28644706 DOI: 10.1200/jop.2016.020321] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Advance care planning (ACP) in hematopoietic stem-cell transplantation (HSCT) is challenging, given the potential for cure despite increased morbidity and mortality risk.The aim of this study was to evaluate ACP and palliative care (PC) integration for patients who underwent HSCT. METHODS A retrospective analysis was conducted and data were extracted from electronic medical records of patients who underwent HSCT between January 2011 and December 2015. Patients who received more than one transplant and who were younger than 18 years of age were excluded. The primary objective was to determine the setting and specialty of the clinician who documented the initial and final code status. Secondary objectives included evaluation of advance directive and/or completion of the Physician Orders for Life-Sustaining Treatment form, PC consultation, hospice enrollment, and location of death. RESULTS The study sample comprised 39% (n = 235) allogeneic and 61% (n = 367) autologous HSCTs. All patients except one (n = 601) had code status documentation, and 99.2% (n = 596) were initially documented as full code. Initial and final code status documentation in the outpatient setting was 3% (n = 17) and 24% (n = 143), respectively. PC consultation occurred for 19% (n = 114) of HSCT patients, with 83% (n = 95) occurring in the hospital. Allogeneic transplant type and age were significantly associated with greater rates of advance directive and/or Physician Orders for Life-Sustaining Treatment completion. Most patients (85%, n = 99) died in the hospital, and few were enrolled in hospice (15%, n = 17). CONCLUSION To our knowledge, this is the largest single-center study of ACP and PC integration for patients who underwent HSCT. Code status documentation in the outpatient setting was low, as well as utilization of PC and hospice services.
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Affiliation(s)
| | - Joseph D Ma
- University of California, San Diego, San Diego, CA
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