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Shimer S, Allen OS, Yang C, Canavan M, Westvold S, Kim N, Morillo J, Parker T, Wallace N, Smith CB, Adelson KB. Prognostic Understanding, Goals of Care, and Quality of Life in Hospitalized Patients with Leukemia or Multiple Myeloma. J Palliat Med 2024; 27:879-887. [PMID: 38990245 DOI: 10.1089/jpm.2023.0530] [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: 07/12/2024] Open
Abstract
Background: Prior studies reveal a lack of illness understanding and prognostic awareness among patients with hematological malignancies. We evaluated prognostic awareness and illness understanding among patients with acute leukemia and multiple myeloma (MM) and measured patient-hematologist discordance. Methods: We prospectively enrolled patients with acute leukemia and MM at Mount Sinai Hospital or Yale New Haven Hospital between August 2015 and February 2020. Patients were administered a survey assessing prognostic awareness, goals of care (GOC), and quality of life. Hematologists completed a similar survey for each patient. We assessed discordance across the cohort of patients and hematologists using the likelihood-ratio chi-square test and within patient-hematologist pairs using the kappa (κ) statistic. Results: We enrolled 185 patients (137 with leukemia and 48 with MM) and 29 hematologists. Among patients, 137 (74%) self-identified as White, 27 (15%) as Black, and 21 (11%) as Hispanic. Across the entire cohort, patients were significantly more optimistic about treatment goals compared with hematologists (p = 0.027). Within patient-hematologist pairs, hematologists were significantly more optimistic than patients with respect to line of treatment (κ = 0.03). For both leukemia and MM cohorts, patients were significantly more likely to respond "don't know" or deferring to a faith-based response with 88 (64%) and 34 (71%), respectively, compared with only 28 (20%) and 11 (23%) of hematologists, respectively. Conclusions: We observed significant discordance regarding prognosis and GOC among patients with hematological malignancies and their hematologists. These data support future interventions to improve prognostic understanding among this patient population to facilitate informed treatment choices.
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Affiliation(s)
- Sophia Shimer
- Yale School of Medicine, New Haven, Connecticut, USA
- Beth Israel Deaconess Medical Center, New Haven, Connecticut, USA
| | - Olivia S Allen
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Chen Yang
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Nina Kim
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Jose Morillo
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Terri Parker
- Beth Israel Deaconess Medical Center, New Haven, Connecticut, USA
| | | | - Cardinale B Smith
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kerin B Adelson
- Yale School of Medicine, New Haven, Connecticut, USA
- MD Anderson Cancer Center, Houston, Texas, USA
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El-Jawahri A, Webb JA, Breffni H, Zimmermann C. Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers. Am Soc Clin Oncol Educ Book 2024; 44:e432196. [PMID: 38768404 DOI: 10.1200/edbk_432196] [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: 05/22/2024]
Abstract
Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jason A Webb
- Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Hannon Breffni
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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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 2024; 27:794-801. [PMID: 38064538 PMCID: PMC11339551 DOI: 10.1089/jpm.2023.0638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [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
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Gebel C, Kruschel I, Bodinger S, Simon ST, Eichenauer DA, Pralong A, Wedding U. Palliative care for patients with hematologic malignancies in Germany: a nationwide survey on everyday practice and influencing factors from the perspective of treating physicians. Ann Hematol 2024; 103:1753-1763. [PMID: 38538976 PMCID: PMC11009764 DOI: 10.1007/s00277-024-05726-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
Integrating palliative care into the treatment of patients with advanced hematological malignancies (HM) remains challenging. To explore treating physicians' perspectives on current palliative care practice and to evaluate factors influencing integration, we conducted a nationwide online survey. Based on literature and expert review, the survey addressed the importance of palliative care, communication about life-threatening conditions, challenges in establishing goals of care, and factors influencing the integration of palliative care. 207 physicians treating patients with HM in Germany participated. We used standard descriptive statistics to analyze quantitative data and a content structuring approach. Most physicians considered palliative care in HM to be very important (60.6%) and discussed life-threatening conditions with more than half of their patients (52%), especially when goals of care were changed (87.0%) or when patients raised the topic (84.0%). Disease-related factors, different professional perspectives on prognosis, and patient hopes were the main barriers to changing goals of care, but collaboration with colleagues and multidisciplinary teams provided important support. Time constraints were identified as the main barrier to integrating palliative care. The majority worked well with palliative care teams. Referral processes and conditions were perceived as minor barriers. The study highlights the need to address barriers to integrating palliative care into the management of patients with advanced HM. Future research should aim at optimizing palliative care for patients with HM.
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Affiliation(s)
- Cordula Gebel
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany.
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany.
| | - Isabel Kruschel
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany
| | - Steffi Bodinger
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany
| | - Steffen T Simon
- Department of Palliative Medicine, Faculty of Medicine and Cologne University Hospital, Center for Integrated Oncology Aachen Bonn Dusseldorf Cologne, Cologne, Germany
| | - Dennis A Eichenauer
- First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Dusseldorf Cologne, University of Cologne, Cologne, Germany
| | - Anne Pralong
- Department of Palliative Medicine, Faculty of Medicine and Cologne University Hospital, Center for Integrated Oncology Aachen Bonn Dusseldorf Cologne, Cologne, Germany
| | - Ulrich Wedding
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Cologne, Germany
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5
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Kim A, O'Callaghan A, Hemmaway C, Johney L, Ho J. Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre. Intern Med J 2024; 54:588-595. [PMID: 37718574 DOI: 10.1111/imj.16235] [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] [Received: 02/06/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand. AIMS This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available. METHODS One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input. RESULTS During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively. CONCLUSIONS The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.
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Affiliation(s)
- Ann Kim
- Adult Hospital Palliative Care Service, Auckland City Hospital, Auckland, New Zealand
| | - Anne O'Callaghan
- Adult Hospital Palliative Care Service, Auckland City Hospital, Auckland, New Zealand
| | - Claire Hemmaway
- Clinical Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Leslie Johney
- Adult Hospital Palliative Care Service, Auckland City Hospital, Auckland, New Zealand
| | - Jess Ho
- School of Medicine, The University of Auckland, Auckland, New Zealand
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Yang D, Newcomb R, Kavanaugh AR, Khalil D, Greer JA, Chen YB, DeFilipp Z, Temel J, Lee SJ, LeBlanc TW, El-Jawahri A. Protocol for multi-site randomized trial of inpatient palliative care for patients with hematologic malignancies undergoing hematopoietic stem cell transplantation. Contemp Clin Trials 2024; 138:107460. [PMID: 38280483 PMCID: PMC10932944 DOI: 10.1016/j.cct.2024.107460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT) commonly experience debilitating physical and psychological symptoms during a 3-4-week-hospitalization. During hospitalization, caregivers (i.e., family and friends) also endure immense emotional stress as they witness their loved one struggle with HSCT toxicities. Yet interventions to improve quality of life (QOL) and reduce psychological distress during HSCT are limited. METHODS We are conducting a multi-site randomized controlled trial of inpatient integrated palliative and transplant care versus usual care in 360 patients hospitalized for HSCT and their caregivers at three academic centers. Intervention participants meet with a palliative care clinician at least twice weekly during the HSCT hospitalization to address their physical and psychological symptoms. Patients assigned to usual care receive all supportive care measures provided by the HSCT team and could be seen by palliative care upon request. We assess patient QOL (Functional Assessment of Cancer Therapy (FACT) - Bone Marrow Transplant), depression and anxiety symptoms (Hospital Anxiety and Depression Scale), post-traumatic stress (PTSD) symptoms (PTSD checklist), symptom burden (Edmonton Symptom Assessment Scale), and fatigue (FACT-Fatigue) as well as caregiver-reported outcomes at baseline, 2 weeks, 3-months, 6-months, and 12-months post-HSCT. The primary endpoint is to compare QOL at week-2 during HSCT hospitalization between the two groups when patients typically experience their QOL nadir during HSCT. CONCLUSIONS This multi-site trial will define the role of palliative care for improving QOL and care for patients with hematologic malignancies undergoing HSCT and their caregivers.
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Affiliation(s)
- Daniel Yang
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Richard Newcomb
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Medical School, Boston, MA 02114, United States of America.
| | - Alison R Kavanaugh
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Dania Khalil
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Joseph A Greer
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Medical School, Boston, MA 02114, United States of America
| | - Yi-Bin Chen
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Medical School, Boston, MA 02114, United States of America
| | - Zachariah DeFilipp
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Medical School, Boston, MA 02114, United States of America
| | - Jennifer Temel
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Medical School, Boston, MA 02114, United States of America
| | - Stephanie J Lee
- Division of Clinical Research, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, United States of America
| | - Thomas W LeBlanc
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, NC, United States of America
| | - Areej El-Jawahri
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America; Harvard Medical School, Boston, MA 02114, United States of America
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7
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Alnaeem MM, Shehadeh A, Nashwan AJ. The experience of patients with hematological malignancy in their terminal stage: a phenomenological study from Jordan's perspective. BMC Palliat Care 2024; 23:36. [PMID: 38336650 PMCID: PMC10854087 DOI: 10.1186/s12904-024-01373-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients diagnosed with hematological malignancies residing in low-middle-income countries undergo significant physical and psychological stressors. Despite this, only 16% of them receive proper care during the terminal stages. It is therefore crucial to gain insight into the unique experiences of this population. AIM To have a better understanding of the needs and experiences of adult patients with advanced hematological malignancy by exploring their perspectives. METHODS A qualitative interpretive design was employed to collect and analyze data using a phenomenological approach. The study involved in-depth interviews with ten participants aged between 49 and 65 years, utilizing a semi-structured approach. RESULTS Two primary themes emerged from the participants' experiences of reaching the terminal stage of illness: "Pain, Suffering, and Distress" and "Spiritual Coping." The first theme encompassed physical and emotional pain, suffering, and distress, while the second theme was centered on the participants' spiritual coping mechanisms. These coping mechanisms included seeking comfort in religious practices, relying on spiritual support from family and friends, and finding solace in their beliefs and faith. CONCLUSION Patients with hematological malignancies in the terminal stages of their disease experience severe pain, considerable physical and psychosocial suffering, and spiritual distress. While they require support to cope with their daily struggles, their experiences often go unnoticed, leading to disappointment and loss of dignity. Patients mainly rely on their spirituality to cope with their situations. Healthcare providers must acknowledge these patients' needs and provide more holistic and effective care.
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Affiliation(s)
- Mohammad M Alnaeem
- Palliative Care and Pain Management Program, School of Nursing, Al-Zaytoonah University of Jordan, Airport Street, 11733, Amman, Jordan
| | - Anas Shehadeh
- Community Health Nursing, School of Nursing, Al-Zaytoonah University of Jordan, Airport Street, 11733, Amman, Jordan
| | - Abdulqadir J Nashwan
- Director of Nursing for Education and Practice Development, Nursing Department, Hamad Medical Corporation, Doha, Qatar.
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Allende-Pérez S, García-Salamanca MF, Peña-Nieves A, Ramírez-Ibarguen A, Verástegui-Avilés E, Hernández-Lugo I, LeBlanc TW. Palliative Care in Patients With Hematological Malignancies. We Have a Long Way to Go…. Am J Hosp Palliat Care 2023; 40:1324-1330. [PMID: 36592366 DOI: 10.1177/10499091221149150] [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: 01/03/2023] Open
Abstract
Background: Patients with hematological malignancies have significant and diverse palliative care needs but are not usually referred to specialist palliative care services in a timely manner, if at all. Objective: To identify the characteristics of patients with hematological malignancies referred to the palliative care service in a tertiary hospital in Mexico City. Patients: Retrospective study including consecutive patients with hematological malignancies referred to palliative care services at Mexico's National Cancer Institute. Results: Between 2011 and 2019, 5,017 patients with hematological malignancies were evaluated for first time at Mexico's National Cancer Institute. Of these, 9.1% (n = 457) were referred to palliative care. Most were male (53.4%), with a median age of 58 years. The most frequent diagnosis was non-Hodgkin lymphoma (54.9%). The primary indication for referral to palliative care was for cases wherein chemotherapy was no longer an option (disease refractory to treatment, 42.8%). The median time of referral to the palliative care service occurred 11.2 months after the first evaluation at the National Cancer Institute and death occurred on median 1.1 months after the first palliative care evaluation. Conclusion: Patients with hematological neoplasms are infrequently referred to Palliative Care at the Institute (9.1%). We found no clear referral criteria for Palliative Care referral and note that hematologists' optimism regarding a cure can delay referrals. Clearly, we have a long way to go in improving the number of patients referred, and we still saw frequent referrals near the end of life, but the high rate of outpatient referrals is encouraging.
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Affiliation(s)
| | | | | | | | | | | | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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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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Robbins-Welty GA, Webb JA, Shalev D, El-Jawahri A, Jackson V, Mitchell C, LeBlanc TW. Advancing Palliative Care Integration in Hematology: Building Upon Existing Evidence. Curr Treat Options Oncol 2023; 24:542-564. [PMID: 37017909 PMCID: PMC10074347 DOI: 10.1007/s11864-023-01084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/06/2023]
Abstract
OPINION STATEMENT Patients with hematologic malignancies and their families are among the most distressed of all those with cancer. Despite high palliative care-related needs, the integration of palliative care in hematology is underdeveloped. The evidence is clear that the way forward includes standard-of-care PC integration into routine hematologic malignancy care to improve patient and caregiver outcomes. As the PC needs for patients with blood cancer vary significantly by disease, a disease-specific PC integration strategy is needed, allowing for serious illness care interventions to be individualized to the specific needs of each patient and situation.
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Affiliation(s)
- Gregg A. Robbins-Welty
- Department of Medicine, Duke University School of Medicine Durham, Durham, NC USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Jason A. Webb
- Division of Hematology/Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Dan Shalev
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY USA
- Department of Psychiatry, Weill Cornell Medicine, New York, NY USA
| | - Areej El-Jawahri
- Division of Oncology, Dana Farber, Massachusetts General Hospital, Boston, MA USA
| | - Vicki Jackson
- Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | | | - Thomas W. LeBlanc
- Department of Medicine, Duke University School of Medicine Durham, Durham, NC USA
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, NC USA
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11
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Miyashita N, Ohashi K, Fujita M, Hosoda T, Kawasaki Y, Takimoto M, Onozawa M. Prognostic factors in patients in the terminal phase of haematological malignancies who are receiving home medical care. Br J Haematol 2022; 201:290-301. [PMID: 36572123 DOI: 10.1111/bjh.18623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/01/2022] [Accepted: 12/11/2022] [Indexed: 12/28/2022]
Abstract
Although there are many prognostic models for patients in the terminal phase of solid tumours, a reliable prognostic scoring system in patients in the terminal phase of haematological malignancies (HM) has not been established. We retrospectively evaluated 180 patients in the terminal phase of HM who were receiving home medical care (HMC). Multivariate analyses revealed that clinician's estimate, consciousness, loss of appetite, dyspnoea, neutrophil count, lymphocyte count, and lactate dehydrogenase were associated with overall survival (OS). Based on this result, we developed a novel prognostic scoring system, the Japan palliative haematological oncology prognostic estimates, in which four risk groups were shown to clearly differ in survival (p < 0.001): a low-risk group (n = 41, median OS of 434 days), an intermediate-low-risk group (n = 80, median OS of 112 days), an intermediate-high-risk group (n = 38, median OS of 31.5 days), and a high-risk group (n = 21, median OS of 10 days). This is the first investigation of prognostic factors that influence the OS of patients in the terminal phase of HM who are receiving HMC. Providing patients with reliable information about their prognosis is important for them to consider how to spend their remaining life.
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Affiliation(s)
- Naohiro Miyashita
- Department of Hematology HOME CARE CLINIC N‐CONCEPT Sapporo Japan
- NPO Hemato‐Homecare Network Tokyo Japan
| | - Kota Ohashi
- NPO Hemato‐Homecare Network Tokyo Japan
- TOTUS Home Care Clinic Tokyo Japan
| | - Mariko Fujita
- Medical Home Care Center, Tenri Hospital Tenri Japan
| | - Toru Hosoda
- NPO Hemato‐Homecare Network Tokyo Japan
- Hamorebi Clinic Kamagaya Japan
| | - Yasufumi Kawasaki
- NPO Hemato‐Homecare Network Tokyo Japan
- Kaedenokaze Medical Clinic Tokyo Japan
| | - Madoka Takimoto
- NPO Hemato‐Homecare Network Tokyo Japan
- Kawasaki Nanafuku Clinic Kawasaki Japan
| | - Masahiro Onozawa
- Department of Hematology Hokkaido University Hospital Sapporo Japan
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12
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Morikawa M, Shirai Y. Qualitative Analysis of the Roles of Physicians and Nurses in Providing Decision Support to Patients With Relapsed or Refractory Leukemia and Lymphoma. Cancer Control 2022; 29:10732748221131003. [PMID: 36268680 PMCID: PMC9597203 DOI: 10.1177/10732748221131003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction This study examined the roles of hematologists and other professionals in
providing decision support to patients with relapsed or refractory leukemia
and lymphoma. Methods This was a qualitative study using in-depth semi-structured interviews
involving 11 hematologists in Japan. Result We identified 7 categories related to the roles of hematologists in providing
direct decision support to patients: (1) preparing patients before informed
consent, (2) selecting the information to convey, (3) choosing a method for
conveying this information, (4) respecting the intentions of patients and
their families, (5) directing decision-making and considering fairness, (6)
considering the emotional aspects of patients and their families, and (7)
providing support after discussing treatment options. We also identified the
following 5 subcategories related to the roles of hematologists in
multidisciplinary collaboration: (1) communicating with other professionals,
(2) gathering information from them, (3) providing information to them, (4)
managing the entire medical team, and (5) encouraging nurses to actively
participate with patients throughout the decision-making process. Conclusion Through content analysis, the hematologist’s direct role in decision-making
was extracted as preparation and consideration in situations where
information about decision-making is communicated, and emotional support
after the information is communicated. In addition, active participation in
discussions, sharing information about the patient’s situation and relevant
discussions, and emotional support as the hematologist’s expected roles in
other professions were extracted. The results therefore suggest that a
multidisciplinary team is needed to share information and provide
multidimensional support to patients.
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Affiliation(s)
| | - Yuki Shirai
- Department of Human Health
Sciences, Kyoto
University, Kyoto, Japan,Yuki Shirai, Department of Human Health
Sciences, Kyoto University, 53 Shougoinkawaharacho, Kyoto Sakyo-ku, 606-8507
Kyoto, Japan.
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13
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Patel S, Hoge G, Fellman B, Kaur S, Heung Y, Bruera E, Hui D. Timing of referral to outpatient palliative care for patients with haematologic malignancies. Br J Haematol 2022; 198:974-982. [PMID: 35866185 DOI: 10.1111/bjh.18365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 11/27/2022]
Abstract
Outpatient palliative-care facilitates timely supportive-care access; however, there is a paucity of studies on the timing of referral in the outpatient setting for patients with haematologic malignancy. We examined the trend in timing of outpatient palliative-care referrals over a 10-year period in patients with haematologic malignancies at our comprehensive cancer centre. We included consecutive patients with a diagnosis of haematologic malignancy who were seen at our outpatient palliative-care clinic between 1 January 2010 and 31 December 2019. We collected data on patient characteristics, symptom burden and supportive-care interventions at outpatient palliative-care consultation. The primary outcome was time from outpatient palliative-care consultation to death or last follow-up. In all, 384 patients were referred by leukaemia (n = 143), lymphoma (n = 213), and stem cell transplant (n = 28) services. The median time from outpatient palliative-care referral to death was 3.4 years (IQR 2.4-5.3) with a significant increase in both the number of referrals per year (p = 0.047) and the timing of referral between 2010 and 2019 (p = 0.001). Patients with haematologic malignancies were referred in a timely fashion to our outpatient palliative-care clinic, with earlier and greater numbers of referrals over time.
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Affiliation(s)
- Sameer Patel
- Department of Palliative Care, Rochester General Hospital, Rochester, New York, USA
| | - Geordyn Hoge
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan Fellman
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sharanpreet Kaur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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14
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Nipp RD, Shulman E, Smith M, Brown PMC, Johnson PC, Gaufberg E, Vyas C, Qian CL, Neckermann I, Hornstein SB, Reynolds MJ, Greer J, Temel JS, El-Jawahri A. Supportive oncology care at home interventions: protocols for clinical trials to shift the paradigm of care for patients with cancer. BMC Cancer 2022; 22:383. [PMID: 35397575 PMCID: PMC8994404 DOI: 10.1186/s12885-022-09461-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 03/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients with cancer often endure substantial symptoms and treatment toxicities leading to high healthcare utilization, including hospitalizations and emergency department visits, throughout the continuum of their illness. Innovative oncology care models are needed to improve patient outcomes and reduce their healthcare utilization. Using a novel hospital at home care platform, we developed a Supportive Oncology Care at Home intervention to address the needs of patients with cancer. METHODS We are conducting three trials to delineate the role of Supportive Oncology Care at Home for patients with cancer. The Supportive Oncology Care at Home intervention includes: (1) a hospital at home care model for symptom assessment and management; (2) remote monitoring of daily patient-reported symptoms, vital signs, and body weight; and (3) structured communication with the oncology team. Our first study is a randomized controlled trial to test the efficacy of Supportive Oncology Care at Home versus standard oncology care for improving healthcare utilization, cancer treatment interruptions, and patient-reported outcomes in patients with cancer receiving definitive treatment of their cancer. Participants include adult patients with gastrointestinal and head and neck cancer, as well as lymphoma, receiving definitive treatment (e.g., treatment with curative intent). The second study is a single-arm trial assessing the feasibility and acceptability of the Supportive Oncology Care at Home intervention for hospitalized patients with advanced cancer. Eligible participants include adult patients with incurable cancer who are admitted with an unplanned hospitalization. The third study is a single-arm trial assessing the feasibility and acceptability of the Supportive Oncology Care at Home intervention to enhance the end-of-life care for patients with advanced hematologic malignancies. Eligible participants include adult patients with relapsed or refractory hematologic malignancy receiving palliative therapy or supportive care alone. DISCUSSION These studies are approved by the Dana-Farber/Harvard Cancer Center Institutional Review Board and are being conducted in accordance with the Consolidated Standards of Reporting Trials statement for non-pharmacological trials. This work has the potential to transform the paradigm of care for patients with cancer by providing them with the necessary support at home to improve their health outcomes and care delivery. TRIAL REGISTRATIONS NCT04544046, NCT04637035, NCT04690205.
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Affiliation(s)
- Ryan D Nipp
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
| | | | | | | | - P Connor Johnson
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Eva Gaufberg
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
| | - Charu Vyas
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
| | - Carolyn L Qian
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
| | - Isabel Neckermann
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
| | - Shira B Hornstein
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
| | - Mathew J Reynolds
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
| | - Joseph Greer
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer S Temel
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
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15
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Salas S, Pauly V, Damge M, Orleans V, Fond G, Costello R, Boyer L, Baumstarck K. Intensive end-of-life care in acute leukemia from a French national hospital database study (2017–2018). Palliat Care 2022; 21:45. [PMID: 35366857 PMCID: PMC8976296 DOI: 10.1186/s12904-022-00937-0] [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: 05/25/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background A better understanding of how the care of acute leukemia patients is managed in the last days of life would help clinicians and health policy makers improve the quality of end-of-life care. This study aimed: (i) to describe the intensity of end-of-life care among patients with acute leukemia who died in the hospital (2017–2018) and (ii) to identify the factors associated with the intensity of end-of-life care. Methods This was a retrospective cohort study of decedents based on data from the French national hospital database. The population included patients with acute leukemia who died during a hospital stay between 2017 and 2018, in a palliative care situation (code palliative care Z515 and-or being in a inpatient palliative care support bed during the 3 months preceding death). Intensity end-of-life care was assessed using two endpoints: High intensive end-of-life (HI-EOL: intensive care unit admission, emergency department admission, acute care hospitalization, intravenous chemotherapy) care and most invasive end-of-life (MI-EOL: orotracheal intubation, mechanical ventilation, artificial feeding, cardiopulmonary resuscitation, gastrostomy, or hemodialysis) care. Results A total of 3658 patients were included. In the last 30 days of life, 63 and 13% of the patients received HI-EOL care and MI-EOL care, respectively. Being younger, having comorbidities, being care managed in a specialized hospital, and a lower time in a palliative care structure were the main factors associated with HI-EOL. Conclusions A large majority of French young adults and adults with acute leukemia who died at the hospital experienced high intensity end-of-life care. Identification of factors associated with high-intensity end-of-life care, such as the access to palliative care and specialized cancer center care management, may help to improve end-of-life care quality. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00937-0.
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16
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Artioli G, Ghirotto L, Alquati S, Tanzi S. Behavioral Patterns in Breaking Bad News Communication: An Ethnographic Study with Hematologists. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:2585. [PMID: 35270277 PMCID: PMC8910064 DOI: 10.3390/ijerph19052585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 01/02/2023]
Abstract
Hematologists adequately disclosing bad news is a critical point precluding patient-centered communication. Specific courses on communication for hematologists seem to be rare, as well as research exploring their communicative skills and patterns. We aim at describing the hematologists' behavior during difficult conversations to account for behavioral patterns in communication and provide new insights regarding teaching skills to communicate bad news. We employed a focused visual ethnography to answer the following research: "what are hematologists' behavioral patterns in communicating bad news to patients and families?" The collected data included (1) video recordings, (2) observational field notes, (3) interviews with hematologists. The analysis highlighted four patterns: (1) a technical-defensive pattern, (2) an authoritative pattern, (3) a relational-recursive pattern, and (4) a compassionate sharing pattern. Hematologists seem to have difficulty expressing compassionate caring and empathetic comprehension. Communication skills remain a challenge for hematologists. The study of behavioral patterns can lead to increasingly targeted training interventions for this specific learner population.
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Affiliation(s)
- Giovanna Artioli
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy; (S.A.); (S.T.)
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Sara Alquati
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy; (S.A.); (S.T.)
| | - Silvia Tanzi
- Palliative Care Unit, Azienda USL-IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy; (S.A.); (S.T.)
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17
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Withdrawal: "Assessment of prognostic understanding, perceived goals of care, and quality of life in hospitalized patients with leukemia or multiple myeloma" Olivia S. Allen, Nina Kim, Jose Morillo, Cardinale B. Smith. Cancer 2021; 127:4316. [PMID: 33891716 DOI: 10.1002/cncr.33599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Lee SH, Chou WC, Yang HY, Chen CC, Chang H, Wang PN, Kuo MC, Kao YF, Ho LH, Hsueh SW, Kao CY, Hsueh WH, Hung CY, Hung YS. Utility of Palliative Prognostic Index in Predicting Survival Outcomes in Patients With Hematological Malignancies in the Acute Ward Setting. Am J Hosp Palliat Care 2021; 39:548-554. [PMID: 34196220 DOI: 10.1177/10499091211028820] [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] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The palliative prognostic index (PPI) predicts the life expectancy of patients with terminally ill cancer in hospice settings. This study aimed to evaluate PPI as a prognostic tool for predicting the life expectancy of patients with hematological malignancies admitted to the acute ward. METHODS A total of 308 patients with hematological malignancies admitted to the hematological ward at a medical center between January 2016 and December 2017 were consecutively enrolled. PPI was scored within 24 h of admission. All patients were categorized into 3 groups by PPI for comparing survival and in-hospital mortality rates. RESULTS The median survival times were 38.4, 3.6, and 1.1 months for patients with good, intermediate, and poor prognostic group, respectively. The hazard ratio was 2.31 (95% CI 1.59-3.35, p < 0.001) when comparing the intermediate and good prognosis groups, and 3.90 (95% CI 2.52-6.03, p < 0.001) when comparing the poor and good prognosis groups. Forty-five (14.6%) patients died at discharge; in-hospital mortality rates among the good, intermediate, and poor prognostic groups were 9.0%, 23.4%, and 46.4%, respectively. The adjusted odds ratio for in-hospital mortality was 1.96 (95% CI, 0.80-4.82, p = 0.14) and 5.25 (95% CI, 2.01-13.7, p < 0.001) for patients in the intermediate and poor prognostic groups compared to those in the good prognostic group. CONCLUSION PPI is an accurate prognostic tool for predicting survival times and in-hospital mortality rates in patients with hematological malignancies in an acute ward setting. PPI could assist clinicians in discussing end-of-life issues and in referring patients with hematological malignancies to palliative care.
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Affiliation(s)
- Shu-Hui Lee
- Department of Nursing, Linkou Chang Gung Memorial Hospital, Chang Gung University of Science and Technology, Cardinal Tien Junior College of Healthcare and Management, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Yi Yang
- Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Chia Chen
- Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung Chang
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Nan Wang
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chung Kuo
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Feng Kao
- Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Lun-Hui Ho
- Department of Nursing, Linkou Chang Gung Memorial Hospital, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Shun-Wen Hsueh
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Chen-Yi Kao
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | | | - Chia-Yen Hung
- Division of Hema-oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yu-Shin Hung
- Division of Hema-oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan, Taiwan
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19
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Mo L, Urbauer DL, Bruera E, Hui D. Recommendations for supportive care and best supportive care in NCCN clinical practice guidelines for treatment of cancer: Differences between solid tumor and hematologic malignancy guidelines. Support Care Cancer 2021; 29:7385-7392. [PMID: 34052931 DOI: 10.1007/s00520-021-06245-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/20/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE It is unclear how NCCN guidelines recommend "supportive care" and "best supportive care" in oncology practice. We examined the usage of "supportive care" and "best supportive care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines. METHODS We reviewed all updated NCCN Guidelines for Treatment of Cancer in October 2019. We documented the frequency of occurrence, definition, and timing of introduction of each term. We compared between solid tumor and hematologic malignancy guidelines. RESULTS We identified a total of 37 solid tumor and 16 hematologic guidelines. Thirty-seven (70%) guidelines mentioned "supportive care" and 36 (68%) mentioned "best supportive care." Hematologic guidelines were significantly more likely than solid tumor guidelines to use the term "supportive care" (median occurrence 19 vs. 2; P = 0.001) and to describe "supportive care" as management of cancer-related complications (N = 11/15, 73% vs. N = 2/22, 9%; P < 0.001). Domains of specialist palliative care were infrequently mentioned (N = 10/37, 27%). In contrast, solid tumor guidelines were significantly more likely than hematologic guidelines to mention "best supportive care" (median occurrence 6 vs. 0; P = 0.016). This term was rarely defined and mostly used in the advanced disease setting. CONCLUSION "Supportive care" and "best supportive care" were frequently used in NCCN guidelines, with significant variations in usage between solid tumor and hematologic oncologists. "Supportive care" was mostly limited to management of cancer-related complications and treatment adverse effects in NCCN guidelines, highlighting the need to go beyond the traditional biomedical model to more a patient-centered care model with greater integration of palliative care.
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Affiliation(s)
- Li Mo
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, University of Texas M.D. Anderson Cancer Center, FCT5.6046, 1515 Holcombe, Houston, TX, 77030, USA
- The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Diana L Urbauer
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, University of Texas M.D. Anderson Cancer Center, FCT5.6046, 1515 Holcombe, Houston, TX, 77030, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, University of Texas M.D. Anderson Cancer Center, FCT5.6046, 1515 Holcombe, Houston, TX, 77030, USA.
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20
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Suthumphong C, Tran DB, Ruiz M. Perceptions and Misperceptions of Early Palliative Care Interventions for Patients With Hematologic Malignancies Undergoing Bone Marrow Transplantation. Cureus 2021; 13:e13876. [PMID: 33868840 PMCID: PMC8043049 DOI: 10.7759/cureus.13876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hematopoietic stem cell or bone marrow transplantation (BMT) is one of the most promising and potentially curative therapeutic options available for eligible patients with hematologic malignancies (HMs) or leukemias. However, the nature and clinical course of HMs, specifically for patients undergoing BMT, are associated with significant morbidity, symptomatology, healthcare service utilization, psychosocial and end of life issues, and overall decreased quality of life. Early palliative care (PC) consultations and utilization for patients with HMs have been shown to improve patient outcomes, satisfaction, and autonomy as well as caregiver burden, shared-decision making, and holistic care management. Despite the complexity of care and complications for patients with HM undergoing BMT, early PC interventions are systematically underutilized and understudied in this population compared to patients with solid tumors or non-HMs. Herein, the authors reviewed the current literature and knowledge to assess and report the perceptions and barriers to early PC utilization in the care of patients with HMs undergoing BMT. Clinical and cultural aspects of PC perceptions as well as current PC care models and potential directions for PC implementation were reviewed to inform future research studies and clinical practice guidelines necessary for the improvement of care and quality of life for HM patients undergoing BMT.
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Affiliation(s)
- Corey Suthumphong
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Dan B Tran
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Marco Ruiz
- Translational Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA.,Miami Cancer Institute, Baptist Health South Florida, Miami, USA
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21
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Cheng HWB, Lam KO. Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development? Ann Hematol 2021; 100:601-606. [PMID: 33388859 DOI: 10.1007/s00277-020-04386-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/21/2020] [Indexed: 12/16/2022]
Abstract
While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.
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Affiliation(s)
- Hon Wai Benjamin Cheng
- Medical Palliative Care Team, Department of Medicine & Geriatrics, Tuen Mun Hospital, New Territories, Hong Kong.
| | - Ka On Lam
- Department of Clinical Oncology, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
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22
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Cartoni C, Breccia M, Giesinger JM, Baldacci E, Carmosino I, Annechini G, Palumbo G, Armiento D, Niscola P, Tendas A, Brunetti GA, Minotti C, Marini MG, Reale L, Martone N, Martelli M, Efficace F. Early Palliative Home Care versus Hospital Care for Patients with Hematologic Malignancies: A Cost-Effectiveness Study. J Palliat Med 2020; 24:887-893. [PMID: 33270529 DOI: 10.1089/jpm.2020.0396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: There is paucity of data on the potential value of early palliative home care for patients with hematologic malignancies. Objective: To compare costs, use of resources, and clinical outcomes between an early palliative home care program and standard hospital care for active-advanced or terminal phase patients. Patients and Methods: In this real-life, nonrandomized comparative study, the allocation of advanced/terminal phase patients to either home or hospital was based on pragmatic considerations. Analysis focused on resources use, events requiring blood unit transfusions or parenteral therapy, patient-reported symptom burden, mean weekly cost of care (MWC), cost-minimization difference, and incremental cost-effectiveness ratio (ICER). Results: Of 119 patients, 59 patients cared at home were more debilitated and had a shorter survival than the 60 in hospital group (p = 0.001). Nevertheless, symptom burden was similar in both groups. At home the mean weekly number of transfusions (1.45) was lower than that at hospital (2.77). Higher rate of infections occurred at hospital (54%) versus home (21%; <0.001). MWC for hospitalization was significantly higher in a 3:1 ratio versus home care. Compared with hospital, domiciliary assistance produced a weekly saving of € 2314.9 for the health provider, with a charge of € 85.9 for the family, and was cost-effective by an ICER of € -7013.9 of prevented days of care for avoided infections. Conclusions: Current findings suggest that costs of early palliative home care for patients with hematologic malignancies are lower than standard hospital care costs. Domiciliary assistance may also be cost-effective by reducing the number of days to treat infections.
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Affiliation(s)
- Claudio Cartoni
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Massimo Breccia
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | | | - Erminia Baldacci
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Ida Carmosino
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Giorgia Annechini
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Giovanna Palumbo
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | | | | | | | | | - Clara Minotti
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | | | - Luigi Reale
- Fondazione ISTUD, Institute of Management Studies, Milan, Italy
| | | | - Maurizio Martelli
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA), Health Outcomes Research Unit, Rome, Italy
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23
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Narimatsu H, Sakaguchi M, Nakamura S, Katayama K. Future Patient Incidence in Hemato-Oncology: A Study Using Data from Cancer Registries in Japan. Risk Manag Healthc Policy 2020; 13:2407-2414. [PMID: 33173364 PMCID: PMC7648558 DOI: 10.2147/rmhp.s277207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose The distribution of patients with hematological malignancies is expected to change markedly in the future due to aging of the Japanese population. We assessed the expected incidence rates of leukemia, malignant lymphoma, and multiple myeloma using national population estimates and data from the Kanagawa Cancer Registry. Patients and Methods To evaluate the effects of community aging, we compared expected future incidences of hematological malignancies in Kanagawa with other three areas, namely the Yamagata, Osaka, and Nagasaki prefectures, which have different populations and predicted aging rates. Results The total number of patients newly diagnosed with hematological malignancy in Kanagawa in 2010 was 1970. This was predicted to increase to 2581 by 2025 and to 2712 by 2040. Trends were very similar for all three hematological malignancies. These incidence rates were predicted to increase continuously in patients aged ≥65 years from 2010 to 2040, with a 169% increase in leukemia, a 167% increase in malignant lymphoma, and a 169% increase in multiple myeloma. A continuous increase in the population aged ≥65 years was also noted in the other three prefectures. Conclusion The distribution demographic of patients with hematological malignancies is expected to change in the future as the number of elderly patients increases.
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Affiliation(s)
- Hiroto Narimatsu
- Cancer Prevention & Control Division, Kanagawa Cancer Center Research Institute, Yokohama 241-8515, Japan.,Graduate School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Kanagawa 210-0821, Japan
| | - Masahiko Sakaguchi
- Cancer Prevention & Control Division, Kanagawa Cancer Center Research Institute, Yokohama 241-8515, Japan
| | - Sho Nakamura
- Cancer Prevention & Control Division, Kanagawa Cancer Center Research Institute, Yokohama 241-8515, Japan.,Graduate School of Health Innovation, Kanagawa University of Human Services, Kawasaki, Kanagawa 210-0821, Japan
| | - Kayoko Katayama
- Cancer Prevention & Control Division, Kanagawa Cancer Center Research Institute, Yokohama 241-8515, Japan
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24
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A novel decision aid for acute myeloid leukemia: a feasibility and preliminary efficacy trial. Support Care Cancer 2020; 29:3563-3569. [PMID: 33159220 DOI: 10.1007/s00520-020-05864-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Acute myeloid leukemia (AML) is a hematologic malignancy characterized by a poor prognosis but also a paradoxical possibility of cure. This renders decision-making complex and imminent. Unfortunately, many patients with AML misestimate their prognosis and treatment risk. While decision aids can improve illness understanding and reduce decisional conflict, there are no validated decision aids for AML. We developed and tested a novel AML decision aid (NCT03442452). METHODS Patients (n = 20) were recruited at Duke University from May 2018 to February 2019. Participants completed assessments of AML knowledge and decisional conflict, before and after using the electronic decision aid. The primary endpoint was feasibility (endpoint met if > 80% of study participants completed all study components). Secondary analyses of efficacy were conducted using paired t tests for dependent pre-/post-samples. RESULTS The primary endpoint of feasibility was met (100% of participants completed all study components). Secondary analyses showed improved knowledge and reduced decisional conflict after using the decision aid. Knowledge scores improved from a mean of 11.8 (out of 18) correct items at baseline to 15.1 correct items after using the decision aid (mean difference 3.35; p < 0.0001). Decisional conflict scores reduced significantly from baseline to post-test as well (mean difference - 6.5; p = 0.02). CONCLUSION These findings suggest that our AML decision aid is a useful tool to improve the patient experience and promote shared decision-making in AML. A randomized efficacy trial is planned.
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Tanzi S, De Panfilis L, Costantini M, Artioli G, Alquati S, Di Leo S. Development and preliminary evaluation of a communication skills training programme for hospital physicians by a specialized palliative care service: the 'Teach to Talk' programme. BMC MEDICAL EDUCATION 2020; 20:363. [PMID: 33059642 PMCID: PMC7560022 DOI: 10.1186/s12909-020-02275-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 10/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND There is widespread agreement about the importance of communication skills training (CST) for healthcare professionals caring for cancer patients. Communication can be effectively learned and improved through specific CST. Existing CSTs have some limitations with regard to transferring the learning to the workplace. The aim of the study is developing, piloting, and preliminarily assessing a CST programme for hospital physicians caring for advanced cancer patients to improve communication competences. METHODS This is a Phase 0-I study that follows the Medical Research Council framework; this paper describes the following sections: a literature review on CST, the development of the Teach to Talk training programme (TtT), the development of a procedure for assessing the quality of the implementation process and assessing the feasibility of the implementation process, and the pilot programme. The study was performed at a 900-bed public hospital. The programme was implemented by the Specialized Palliative Care Service. The programme was proposed to 19 physicians from 2 departments. RESULTS The different components of the training course were identified, and a set of quality indicators was developed. The TtT programme was implemented; all the physicians attended the lesson, videos, and role-playing sessions. Only 25% of the physicians participated in the bedside training. It was more challenging to involve Haematology physicians in the programme. CONCLUSIONS The programme was completed as established for one of the two departments in which it was piloted. Thus, in spite of the good feedback from the trainees, a re-piloting of a different training program will be developed, considering in particular the bed side component. The program should be tailored on specific communication attitude and believes, probably different between different specialties.
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Affiliation(s)
- S Tanzi
- Palliative Care Unit, Azienda USL- IRCCS Reggio Emilia, Reggio Emilia, Italy.
- Clinical and Experimental Medicine PhD Programme, University of Modena and Reggio Emilia, Modena, Italy.
| | - L De Panfilis
- Unit of Bioethics, Azienda USL- IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - M Costantini
- Scientific Directorate, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - G Artioli
- Palliative Care Unit, Azienda USL- IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - S Alquati
- Palliative Care Unit, Azienda USL- IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - S Di Leo
- Psycho-oncology Unit, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
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Mo L, Urbauer DL, Bruera E, Hui D. Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer. Oncologist 2020; 26:77-83. [PMID: 32915490 DOI: 10.1002/onco.13515] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/18/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines. MATERIALS AND METHODS We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services. RESULTS We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care. CONCLUSION "Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines. IMPLICATIONS FOR PRACTICE Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.
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Affiliation(s)
- Li Mo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, Houston, Texas, USA.,The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, Sichuan University West China Hospital, Chengdu, Sichuan, People's Republic of China
| | - Diana L Urbauer
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, Houston, Texas, USA
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Thompson LL, Chen ST, Lawton A, Charrow A. Palliative care in dermatology: A clinical primer, review of the literature, and needs assessment. J Am Acad Dermatol 2020; 85:708-717. [PMID: 32800870 DOI: 10.1016/j.jaad.2020.08.029] [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: 12/19/2019] [Revised: 07/09/2020] [Accepted: 08/01/2020] [Indexed: 12/25/2022]
Abstract
Palliative care has been shown to improve quality of life, symptoms, and caregiver burden for a range of life-limiting diseases. Palliative care use among patients with severe dermatologic disease remains relatively unexplored, but the limited available data suggest significant unmet care needs and low rates of palliative care use. This review summarizes current palliative care patterns in dermatology, identifying areas for improvement and future investigation.
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Affiliation(s)
- Leah L Thompson
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Steven T Chen
- Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts; Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Andrew Lawton
- Harvard Medical School, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Alexandra Charrow
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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Sharplin K, Wee LYA, Singhal D, Edwards S, Danner S, Lewis I, Thomas D, Wei A, Yong ASM, Hiwase DK. Outcomes and health care utilization of older patients with acute myeloid leukemia. J Geriatr Oncol 2020; 12:243-249. [PMID: 32713804 DOI: 10.1016/j.jgo.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/27/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The incidence of acute myeloid leukemia (AML) in older patients is increasing, but practice guidelines balancing quality-of-life, time outside of hospital and overall survival (OS) are not established. METHODS We conducted a retrospective analysis comparing time outside hospital, OS and end-of-life care in AML patients ≥60 years treated with intensive chemotherapy (IC), hypomethylating agents (HMA) and best supportive care (BSC) in a tertiary hospital. RESULTS Of 201 patients diagnosed between 2005 and 2015, 54% received IC while 14% and 32% were treated with HMA and BSC respectively. Median OS was significantly higher in patients treated with IC and HMA compared with BSC (11.5 versus 16.2 versus 1.3 months; p < .0001). Median number of hospital admissions for the entire cohort was 3 (1-17) and patients spent <50% of their life after the diagnosis in the hospital setting. Compared to BSC, IC (HR 0.27, p < .0001) and HMA therapy (HR 0.16, p < .0001) were associated with the lower likelihood of spending at least 25% of survival time in hospital. Although 66% patients were referred to palliative care, the interval between referral to death was 24 (1-971) days and 46% patients died in the hospital. CONCLUSION Older patients with AML, irrespective of treatment, require intensive health care resources, are more likely to die in hospital and less likely to use hospice services. Older AML patients treated with disease modifying therapy survive longer than those receiving BSC, and spend >50% of survival time outside the hospital. These data are informative for counselling older patients with AML.
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Affiliation(s)
- Kirsty Sharplin
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia
| | - Li Yan A Wee
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Deepak Singhal
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Suzanne Edwards
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Silke Danner
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia
| | - Ian Lewis
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Daniel Thomas
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Andrew Wei
- Department of Clinical Hematology, Alfred Hospital and Monash University, Melbourne, Australia
| | - Agnes S M Yong
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Devendra K Hiwase
- Haematology, Royal Adelaide Hospital, Port Road, Adelaide, Australia; Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia.
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Gray TF, Temel JS, El-Jawahri A. Illness and prognostic understanding in patients with hematologic malignancies. Blood Rev 2020; 45:100692. [PMID: 32284227 DOI: 10.1016/j.blre.2020.100692] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/04/2020] [Accepted: 04/02/2020] [Indexed: 12/25/2022]
Abstract
It is critical for patients with hematologic malignancies to have an accurate understanding of their illness and prognosis to make informed treatment decisions. Illness and prognostic understanding have primarily been studied in patients with solid tumors, however, data in patients with hematologic malignancies are rapidly growing. Patients with hematologic malignancies often face a unique and unpredictable illness trajectory with the possibility of cure persisting even in relapsed and refractory settings. These patients often require intensive therapies such as high-dose chemotherapy, hematopoietic stem cell transplantation (HCT), or CAR T-cell therapy, which carry with them significant risk of morbidity, mortality, and prognostic uncertainty. In this review article, we first described the current literature on illness and prognostic understanding in patients with hematologic malignancies including 1) patients' varying desire for prognostic information; (2) patients' prognostic misperceptions, (3) the association between patients' prognostic understanding and their psychological outcomes; and (4) barriers to prognostic understanding. Next, we examined insights gained from the literature about illness and prognostic understanding in patients with solid tumors to guide our understanding of the research gaps in hematologic malignancies. Future studies are needed to better delineate the longitudinal relationship between prognostic understanding, psychological distress, and coping in patients with hematologic malignancies. Strategies such as communicating effectively about prognosis, cultivating adaptive coping in the face of a terminal prognosis, and integrating specialty palliative care for patients with hematologic malignancies have the potential to improve patients' prognostic understanding and their quality of life and care.
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Affiliation(s)
- Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Areej El-Jawahri
- Massachusetts General Hospital Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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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: 100] [Impact Index Per Article: 25.0] [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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Intensive care unit outcomes in patients with hematological malignancy. BLOOD SCIENCE 2020; 2:33-37. [PMID: 35399861 PMCID: PMC8974903 DOI: 10.1097/bs9.0000000000000038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/12/2019] [Indexed: 11/26/2022] Open
Abstract
Hematological malignancies are usually life-limiting conditions. Limitations of care need to be decided early, based on acceptability to the patient, family, physician, and community. Inappropriate intensive care unit (ICU) admission is likely to result in significant physical, psychological, and economic burden. There is little published on the impact of non-acute preadmission disease factors on ICU outcomes in hematological malignancies.
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Specific challenges in end-of-life care for patients with hematological malignancies. Curr Opin Support Palliat Care 2019; 13:369-379. [DOI: 10.1097/spc.0000000000000470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Difficulties in providing palliative care in identified palliative care beds: An exploratory survey. Presse Med 2019; 48:e209-e215. [PMID: 31421945 DOI: 10.1016/j.lpm.2018.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 12/22/2017] [Accepted: 10/09/2018] [Indexed: 11/20/2022] Open
Abstract
AIM Identified Palliative Care Beds (Lits Identifiés Soins Palliatifs - LISPs) is a French specificity. Primarily created to integrate palliative care culture into conventional hospital units, the relevance of this measure became a controversial issue. Nowadays, hospital teams continue to frequently encounter complex situations regarding medical care for palliative patients. To the best of our knowledge, there is only one study, a quantitative one, bridging the gap about that subject. It showed failure in practicing palliative care work around LISP. Our study is based on a qualitative method that complements the quantitative study. It aimed to describe difficulties that limit palliative care practices in managing adult patients in LISP. METHOD This qualitative exploratory survey was conducted with a sample of health service professionals (n=20), from senior physicians to caregivers. Each semi-structured interview included open questions regarding their experiences, feelings and difficulties with palliative care practices on LISP. It also included closed questions concerning interviewee's demographics and career course. The data for this research were submitted to a two-stage analysis: first, a global review of each interview was performed to identify trends. Then, a detailed breakdown, question by question, was implemented. RESULTS From a quantitative perspective, the interviews revealed 305 difficulties, indicating the gaps and barriers limiting the implementation of a palliative approach in these services. From a qualitative perspective, five topics raised our attention by their recurrence in discourses: (1) partial knowledge about palliative care definition and legislation mostly due to a lack of training; (2) need for time; (3) need for human resources; (4) need for communication; (5) hard time in transitioning from curative to palliative care. PERSPECTIVE This survey gives the opportunity to understand health service professionals' difficulties in practicing palliative care in conventional medical services. It raises the central issue of the pricing reform on the health institutes activity. It also provides angles of inquiry to improve LISP effectiveness. This qualitative and descriptive study was designed to explore difficulties in practicing palliative care around LISP. Nevertheless, according to the size of the sample, results will need to be confirmed by a more extensive qualitative survey.
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Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage 2019; 58:72-79.e2. [PMID: 31034869 PMCID: PMC6849206 DOI: 10.1016/j.jpainsymman.2019.04.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 12/22/2022]
Abstract
CONTEXT Optimal advance care planning allows patients to articulate their values as a touchstone for medical decision making. Ideally, this occurs when patients are clinically stable, and with opportunities for iteration as the clinical situation unfolds. OBJECTIVES Testing feasibility and acceptability in busy outpatient oncology clinics of a novel program of systematic, oncology nurse-led values discussions with all new cancer patients. METHODS Within an institutional initiative integrating primary and specialist palliative care from diagnosis for all cancer patients, oncology nurses were trained to use specific questions and an empathic communication framework to discuss health-related values during outpatient clinic visits. Nurses summarized discussions on a template for patient verification, oncologist review, and electronic medical record documentation. Summaries were reviewed with the patient at least quarterly. Feasibility and acceptability were evaluated in three clinics for patients with hematologic or gastrointestinal malignancies. RESULTS Oncology nurses conducted 177 total discussions with 67 newly diagnosed cancer patients (17 with hematologic and 50 with gastrointestinal malignancies) over two years. No patient declined participation. Discussions averaged eight minutes, and all patients verified values summaries. Clinic patient volume was maintained. Of 31 patients surveyed, 30 (97%) reported feeling comfortable with the process, considered it helpful, and would recommend it to others. Clinicians strongly endorsed the values discussion process. CONCLUSION Nurse-led discussions of patient values soon after diagnosis are feasible and acceptable in busy oncology clinics. Further research will evaluate the impact of this novel approach on additional patient-oriented outcomes after broader dissemination of this initiative throughout our institution.
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Affiliation(s)
- Andrew S Epstein
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA.
| | - Anjali V Desai
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Danielle Romano
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Peter J Wan
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kelly Anderson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dana Kramer
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Virginia V Klimek
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | | | - Diane L Reidy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | | | - Elizabeth Cruz
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
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McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, Howard MR, Howell DA. Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study. Eur J Oncol Nurs 2019; 39:70-80. [PMID: 30850141 PMCID: PMC6417764 DOI: 10.1016/j.ejon.2019.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/04/2018] [Accepted: 02/06/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Patients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients' places of care and death. METHOD Qualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach. RESULTS Five inter-related factors were identified as contributing to the likelihood of patients' receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home. CONCLUSIONS Hospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
| | - Anne C Garry
- Department of Palliative Care, York Hospital, York, YO31 8HE, UK.
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK.
| | - Russell D Patmore
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull, HU16 5JQ, UK.
| | - Martin R Howard
- Department of Haematology, York Hospital, York, YO31 8HE, UK.
| | - Debra A Howell
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
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Capodanno I, Tamagnini E, Alfieri P, Codeluppi K, Luminari S, Merli F. Home care of acute leukaemia patients: From active therapy to end‐of‐life and palliative care. The 3‐year experience of a single centre. Eur J Haematol 2019; 102:424-431. [DOI: 10.1111/ejh.13224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/08/2019] [Accepted: 02/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Isabella Capodanno
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Enrica Tamagnini
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Pierluigi Alfieri
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Katia Codeluppi
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Stefano Luminari
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Francesco Merli
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
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Soares LGL, Gomes RV, Japiassu AM. Trends in Health-Care Utilization at the End of Life Among Patients With Hematologic Malignancies in a Middle-Income Country: Challenges and Opportunities in Brazil. Am J Hosp Palliat Care 2019; 36:775-779. [DOI: 10.1177/1049909119828086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Patients with hematologic malignancies (HMs) often receive poor-quality end-of-life care. This study aimed to identify trends in end-of-life care among patients with HM in Brazil. We conducted a retrospective cohort study (2015-2018) of patients who died with HM, using electronic medical records linked to health insurance databank, to evaluate outcomes consistent with health-care resource utilization at the end of life. Among 111 patients with HM, in the last 30 days of life, we found high rates of emergency department visits (67%, n = 75), intensive care unit admissions (56%, n = 62), acute renal replacement therapy (10%, n = 11), blood transfusions (45%, n = 50), and medical imaging utilization (59%, n = 66). Patients received an average of 13 days of inpatient care and the majority of them died in the hospital (53%, n = 58). We also found that almost 40% of patients (38%, n = 42) used chemotherapy in the last 14 days of life. These patients were more likely to be male (64% vs 22%; P < .001), to receive blood transfusions (57% vs 38%; P = .05), and to die in the hospital (76% vs 39%; P = .009) than patients who did not use chemotherapy in the last 14 days of life. This study suggests that patients with HM have high rates of health-care utilization at the end of life in Brazil. Patients who used chemotherapy in the last 14 days of life were more likely to receive blood transfusions and to die in the hospital.
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Affiliation(s)
- Luiz Guilherme L. Soares
- Department of Health Services and Costs, End of Life Care Study Group, Unimed Federação Rio de Janeiro, Rio de Janeiro, Brazil
| | - Renato Vieira Gomes
- Department of Health Services and Costs, End of Life Care Study Group, Unimed Federação Rio de Janeiro, Rio de Janeiro, Brazil
| | - André M. Japiassu
- Research Laboratory of Intensive Care Medicine, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Ofran Y, Bar-Sela G, Toledano M, Kushnir I, Moalem B, Gil W, Kazman N, Fineman R. Palliative care service incorporated in a hematology department: a working model fostering changes in clinical practice. Leuk Lymphoma 2019; 60:2079-2081. [DOI: 10.1080/10428194.2018.1564826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Gil Bar-Sela
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Department of Oncology, Rambam Health Care Campus, Haifa, Israel
| | - Miriam Toledano
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Irit Kushnir
- Social Services, Rambam Health Care Campus, Haifa, Israel
| | - Bathen Moalem
- Social Services, Rambam Health Care Campus, Haifa, Israel
| | - Woukelyne Gil
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Natalie Kazman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Riva Fineman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
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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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El-Jawahri A, LeBlanc TW, Burns LJ, Denzen E, Meyer C, Mau LW, Roeland EJ, Wood WA, Petersdorf E. What do transplant physicians think about palliative care? A national survey study. Cancer 2018; 124:4556-4566. [PMID: 30289980 PMCID: PMC6289734 DOI: 10.1002/cncr.31709] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/02/2018] [Accepted: 07/12/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Despite its established benefits, palliative care (PC) is rarely utilized for hematopoietic stem cell transplant (HSCT) patients. We sought to examine transplant physicians' perceptions of PC. METHODS We conducted a cross-sectional survey of transplant physicians recruited from the American-Society-for-Blood-and-Marrow-Transplantation. Using a 28-item questionnaire adapted from prior studies, we examined physicians' access to PC services, and perceptions of PC. We computed a composite score of physicians' attitudes about PC (mean = 16.9, SD = 3.37) and explored predictors of attitudes using a linear mixed model. RESULTS 277/1005 (28%) of eligible physicians completed the questionnaire. The majority (76%) stated that they trust PC clinicians to care for their patients, but 40% felt that PC clinicians do not have enough understanding to counsel HSCT patients about their treatments. Most endorsed that when patients hear the term PC, they feel scared (82%) and anxious (76%). Nearly half (46%) reported that the service name 'palliative care' is a barrier to utilization. Female sex (β = 0.85, P = .024), having <10 years of clinical practice (β = 1.39, P = .004), and perceived quality of PC services (β = 0.60, P < .001) were all associated with a more positive attitude towards PC. Physicians with a higher sense of ownership over their patients' PC issues (β = -0.36, P < .001) were more likely to have a negative attitude towards PC. CONCLUSIONS The majority of transplant physicians trust PC, but have substantial concerns about PC clinicians' knowledge about HSCT and patients' perception of the term 'palliative care'. Interventions are needed to promote collaboration, improve perceptions, and enhance integration of PC for HSCT recipients.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, Boston MA
- Harvard Medical School, Boston MA
| | | | - Linda J. Burns
- National Marrow Donor Program/Be The Match and Center for International Blood and Marrow Transplant Research, Minneapolis MN
| | - Ellen Denzen
- National Marrow Donor Program/Be The Match and Center for International Blood and Marrow Transplant Research, Minneapolis MN
| | - Christa Meyer
- National Marrow Donor Program/Be The Match and Center for International Blood and Marrow Transplant Research, Minneapolis MN
| | - Lih-wen Mau
- National Marrow Donor Program/Be The Match and Center for International Blood and Marrow Transplant Research, Minneapolis MN
| | - Eric J. Roeland
- University of California San Diego Moores Cancer Center, Oncology & Palliative Care, la Jolla, CA
| | - William A. Wood
- University of North Carolina – Chapel Hill Bone Marrow Transplant Program, Chapel Hill, NC
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Corsi DC, Turriziani A, Cavanna L, Morino P, Ribecco AS, Ciaparrone M, Lanzetta G, Pinto C, Zagonel V. Consensus document of the Italian Association of Medical Oncology and the Italian Society of Palliative Care on early palliative care. TUMORI JOURNAL 2018; 105:103-112. [PMID: 30157701 DOI: 10.1177/0300891618792478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A consensus document on early palliative care was produced by a committed Working Group of the Italian Society of Medical Oncology and the Italian Society of Palliative Care to improve the early integration of palliative care in medical oncology and to stimulate and guide the choices of those who daily face the problems of advanced stage cancer patients. The simultaneous administration of antineoplastic treatments and early palliative care was shown to be beneficial in metastatic cancer pathway outcomes. Patients who could benefit from early palliative care are those with an advanced cancer at presentation, a compromised PS for cancer, and/or morbidities, and who are too frail to receive treatment. According to the Bruera practice models, in which the combination of cancer management with early palliative care can be offered, three groups of patients needing simultaneous care were identified and three different models of the delivery of palliative care were proposed. In patients with good prognosis and low need of simultaneous care, the solo practice model and the request for consultations were suggested, while in patients with poor prognosis disease with high need of simultaneous care and in conditions with high need of simultaneous care, regardless of cancer prognosis, the integrated care approach should be offered. Palliative care consultation services are seldom accessible in the majority of Italian hospitals; thus the application of various practice models depends on available resources, and a shared care model with the structures of palliative care operating in the area is often required.
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Affiliation(s)
- Domenico C Corsi
- 1 Medical Oncology Unit, Fatebenefratelli-Isola Tiberina Hospital, Rome, Italy
| | - Adriana Turriziani
- 2 Palliative Care Unit, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Luigi Cavanna
- 3 Department of Hematology and Oncology, Medical Oncology Unit, Piacenza Hospital, Piacenza, Italy
| | - Piero Morino
- 4 Coordination of Palliative Care, Azienda USL Toscana Centro, Florence, Italy
| | - Angela S Ribecco
- 5 Department of Oncology, Azienda USL Toscana Centro, Medical Oncology Unit, S. Giovanni di Dio Hospital, Florence, Italy
| | - Marco Ciaparrone
- 1 Medical Oncology Unit, Fatebenefratelli-Isola Tiberina Hospital, Rome, Italy
| | | | - Carmine Pinto
- 7 Department of Medical Oncology, S. Maria Hospital-IRCCS, Reggio Emilia, Italy
| | - Vittorina Zagonel
- 8 Department of Clinical & Experimental Oncology, Medical Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
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Kirtane K, Downey L, Lee SJ, Curtis JR, Engelberg RA. Intensity of End-of-Life Care for Patients with Hematologic Malignancies and the Role of Race/Ethnicity. J Palliat Med 2018; 21:1466-1471. [PMID: 29975599 DOI: 10.1089/jpm.2018.0152] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Racial/ethnic minority patients with nonhematologic malignancies (non-HM) have lower rates of hospice care, advance directive use, and palliative care utilization than non-Hispanic white (NHW) patients. Less is known regarding racial/ethnic minority patients with hematologic malignancies (HM). OBJECTIVES To study hospital utilization among racial/ethnic minority patients with HM and compare end-of-life outcome measures to patients with non-HM. METHODS We performed a retrospective cohort study (2010-2015) using electronic health records from an integrated academic health center to study differences in hospital utilization patterns and documentation of advance care planning between patients with HM and non-HM. In the subgroup with hematologic malignancy, we examined outcomes associated with racial/ethnic minority status. RESULTS Among all patients in the last 30 days of life, those with HM had higher rates of inpatient care (odds ratio [OR], 1.96; 95% CI: 1.74-2.20; p < 0.001) and intensive care unit (ICU) care (OR, 3.50; 95% CI: 3.05-4.03; p < 0.001). Patients with HM were more likely to die in a hospital (OR, 2.75; 95% CI: 2.49-3.04; p < 0.001) than those with non-HM. Furthermore, during the last 30 days of life, among patients with HM, racial/ethnic minority patients were more likely to have more than one emergency room visit (OR, 6.81; 95% CI: 1.34-33.91; p = 0.02), 14+ days of inpatient care (OR, 1.60; 95% CI: 1.08-2.35; p = 0.02), longer stays in the ICU (OR, 1.26; 95% CI: 1.04-1.52; p = 0.02), and lower rates of advance directive documentation (OR, 0.60; 95% CI: 0.44-0.82; p < 0.01) than NHWs. CONCLUSION Our findings suggest that racial/ethnic minority patients with HM have higher utilization of care at the end-of-life and lower rates of advance directives compared with NHW patients.
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Affiliation(s)
- Kedar Kirtane
- 1 Fred Hutchinson Cancer Research Center, University of Washington , Seattle, Washington
| | - Lois Downey
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,3 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Stephanie J Lee
- 4 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - J Randall Curtis
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,3 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 2 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,3 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
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Kaye EC, Jerkins J, Gushue CA, DeMarsh S, Sykes A, Lu Z, Snaman JM, Blazin L, Johnson LM, Levine DR, Morrison RR, Baker JN. Predictors of Late Palliative Care Referral in Children With Cancer. J Pain Symptom Manage 2018; 55:1550-1556. [PMID: 29427739 PMCID: PMC6223026 DOI: 10.1016/j.jpainsymman.2018.01.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/23/2018] [Accepted: 01/26/2018] [Indexed: 01/15/2023]
Abstract
CONTEXT Early integration of palliative care (PC) in the management of children with high-risk cancer is widely endorsed by patients, families, clinicians, and national organizations. However, optimal timing for PC consultation is not standardized, and variables that influence timing of PC integration for children with cancer remain unknown. OBJECTIVES To investigate associations between demographic, disease, treatment, and end-of-life attributes and timing of PC consultation for children with high-risk cancer enrolled on a PC service. METHODS A comprehensive standardized tool was used to abstract data from the medical records of 321 patients treated at a large academic pediatric cancer center, who died between 2011 and 2015. RESULTS Gender, race, ethnicity, enrollment on a Phase I protocol, number of high-acuity hospitalizations, and receipt of cardiopulmonary resuscitation were not associated with timing of PC involvement. Patients with hematologic malignancy, those who received cancer-directed therapy during the last month of life, and those with advance directives documented one week or less before death had higher odds of late PC referral (malignancy: odds ratio [OR] 3.24, P = 0.001; therapy: OR 4.65, P < 0.001; directive: OR 4.81, P < 0.0001). Patients who received hospice services had lower odds of late PC referral <30 days before death (OR 0.31, P < 0.001). CONCLUSION Hematologic malignancy, cancer-directed therapy at the end of life, and delayed documentation of advance directives are associated with late PC involvement in children who died of cancer. Identification of these variables affords opportunities to study targeted interventions to enhance access to earlier PC resources and services for children with high-risk cancer and their families.
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Affiliation(s)
- Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
| | - Jonathan Jerkins
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA; University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Samantha DeMarsh
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio, USA
| | - April Sykes
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zhaohua Lu
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer M Snaman
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lindsay Blazin
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Deena R Levine
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - R Ray Morrison
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Prod'homme C, Jacquemin D, Touzet L, Aubry R, Daneault S, Knoops L. Barriers to end-of-life discussions among hematologists: A qualitative study. Palliat Med 2018; 32:1021-1029. [PMID: 29756557 DOI: 10.1177/0269216318759862] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Integrated palliative care is correlated with earlier end-of-life discussion and improved quality of life. Patients with haematological malignancies are far less likely to receive care from specialist palliative or hospice services compared to other cancers. AIM The main goal of this study was to determine hematologists' barriers to end-of-life discussions when potentially fatal hematological malignancies recur. DESIGN Qualitative grounded theory study using individual interviews. SETTING/PARTICIPANTS Hematologists ( n = 10) from four hematology units were asked about their relationships with their patients and their attitudes toward prognosis and end-of-life discussions at the time of recurrence. RESULTS As long as there are potential treatments, hematologists fear that end-of-life discussions may undermine their relationship and the patient's trust. Because of their own representations, hematologists have great difficulty opening up to their patients' end-of-life wishes. When prognosis is uncertain, negative outcome, that is, death, is not fully anticipated. Persistent hope silences the threat of death. CONCLUSION This study reveals some of the barriers clinicians face in initiating early discussion about palliative care or patients' end-of-life care plan. These difficulties may explain why early palliative care is little integrated into the hematology care model.
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Affiliation(s)
- Chloé Prod'homme
- 1 ETHICS (Experiment, Transhumanism, Human Interactions, Care and Society) - EA7446, Lille Catholic University, Lille, France.,2 Department of Hematology, CHU Lille, Lille, France.,3 Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Dominique Jacquemin
- 1 ETHICS (Experiment, Transhumanism, Human Interactions, Care and Society) - EA7446, Lille Catholic University, Lille, France.,4 IREC, Université Catholique de Louvain, Brussels, Belgium
| | - Licia Touzet
- 5 Department of Palliative Medicine, CHU Lille, Lille, France
| | - Regis Aubry
- 6 Palliative Care Unit, Jean Minjoz Hospital, Besancon, France
| | - Serge Daneault
- 7 Department of Palliative Care, Montreal University, Montreal, QC, Canada
| | - Laurent Knoops
- 4 IREC, Université Catholique de Louvain, Brussels, Belgium.,8 Unité de Soins Continus, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Mitchell SA. Palliative care during and following allogeneic hematopoietic stem cell transplantation. Curr Opin Support Palliat Care 2018; 12:58-64. [PMID: 29303840 PMCID: PMC5803752 DOI: 10.1097/spc.0000000000000327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize recent literature regarding the provision of palliative care to patients during and following allogeneic hematopoietic stem cell transplantation (HSCT), highlighting factors which mediate impairments in health-related quality of life in this patient population, and the intervention approaches and models of care delivery that clinicians can consider to address unmet needs for palliative care and to strengthen patient and family resiliency. RECENT FINDINGS Provision of palliative care simultaneous with the delivery of treatment directed at the underlying malignancy has emerged as a recommended practice for patients with advanced cancer and high-symptom burden, and a recent randomized trial demonstrates the effectiveness of early palliative care in reducing some of the symptom burden and mood disturbances associated with HSCT. Although more research is needed, there is an expanding body of research-tested interventions to ameliorate the physical and psychological morbidity of HSCT across the transplant trajectory. SUMMARY Palliative care interventions delivered by an interdisciplinary team that includes transplant clinicians and palliative care across the HSCT trajectory can alleviate physical and psychological morbidity, thereby improving the patient and family experience of HSCT.
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Affiliation(s)
- Sandra A Mitchell
- Division of Cancer Control and Population Sciences, Outcomes Research Branch, National Cancer Institute, Rockville, Maryland, USA
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McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, Howard MR, Howell DA. Palliative care specialists' perceptions concerning referral of haematology patients to their services: findings from a qualitative study. BMC Palliat Care 2018; 17:33. [PMID: 29466968 PMCID: PMC5822662 DOI: 10.1186/s12904-018-0289-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/13/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Haematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals. METHODS We conducted a qualitative study, set within the United Kingdom's (UK's) Haematological Malignancy Research Network (HMRN: www.hmrn.org ), a population-based cohort in the North of England. In-depth, semi-structured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the 'Framework' method. RESULTS Study participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of inter-disciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to 'flag' patients' needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time. CONCLUSIONS This is the first UK study to explore SPC practitioners' perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK
| | - Anne C Garry
- Department of Palliative Care, York Hospital, York, YO31 8HE, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| | - Russell D Patmore
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Martin R Howard
- Department of Haematology, York Hospital, York, YO31 8HE, UK
| | - Debra A Howell
- Epidemiology & Cancer Statistics Group, University of York, York, YO10 5DD, UK.
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Moreno-Alonso D, Porta-Sales J, Monforte-Royo C, Trelis-Navarro J, Sureda-Balarí A, Fernández De Sevilla-Ribosa A. Palliative care in patients with haematological neoplasms: An integrative systematic review. Palliat Med 2018; 32:79-105. [PMID: 29130387 DOI: 10.1177/0269216317735246] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies. AIM To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments. DESIGN Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240). DATA SOURCES PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies. RESULTS The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking. CONCLUSION Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.
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Affiliation(s)
- Deborah Moreno-Alonso
- 1 Palliative Care Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep Porta-Sales
- 1 Palliative Care Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristina Monforte-Royo
- 2 Nursing, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Barcelona, Spain
| | - Jordi Trelis-Navarro
- 1 Palliative Care Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Sureda-Balarí
- 3 Clinical Haematology Service, Institut Catala d' Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
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Porta-Sales J, Guerrero-Torrelles M, Moreno-Alonso D, Sarrà-Escarré J, Clapés-Puig V, Trelis-Navarro J, Sureda-Balarí A, Fernández De Sevilla-Ribosa A. Is Early Palliative Care Feasible in Patients With Multiple Myeloma? J Pain Symptom Manage 2017; 54:692-700. [PMID: 28807703 DOI: 10.1016/j.jpainsymman.2017.04.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/11/2017] [Accepted: 04/11/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT Evidence for the benefits of early palliative care (EPC) in patients with solid tumors is strong, but EPC has received scant attention in hematologic malignancies. OBJECTIVE To assess the benefits of outpatient-based EPC for symptom control in patients with multiple myeloma. METHODS Retrospective study of patients attending the Multiple Myeloma Palliative Care Clinic at our hospital in the year 2013 (February 1-December 31). The following symptoms were assessed at baseline and at three follow-up consultations using a Numerical Visual Scale (0 = no symptoms; 10 = worst possible): pain, anorexia, constipation, insomnia, nausea/vomiting, dyspnea, anxiety, and sadness. Physical and emotional symptom burden scores were calculated. Pain interference with general activity, sleep, and mood was also evaluated. RESULTS About 67 patients were included. The proportion of patients reporting moderate-to-severe pain (Numerical Visual Scale ≥5) decreased significantly from baseline to the final follow-up: worst pain decreased from 57% to 18% (P < 0.0001), whereas average pain fell from 24% to 2% (P < 0.0001). The percentage of patients reporting no pain interference increased significantly from baseline: general activity (52% vs. 82%; P = 0.0001), sleep (73% vs. 91%; P = 0.01), and mood (52% vs. 87.5%; P = 0.0001). Physical and emotional symptom burden also improved, with significantly fewer patients reporting depression (13% vs. 5%; P = 0.001). Most patients (86.6%) were alive and still attending the Multiple Myeloma Palliative Care Clinic at study end. CONCLUSIONS These findings indicate that EPC is feasible in patients with multiple myeloma. Pain and other symptoms were well controlled.
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Affiliation(s)
- Josep Porta-Sales
- Palliative Care Service, Institut Català d'Oncologia, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat. Facultat de Medicina i Ciències de la Salut, Universitat Internacional de Catalunya, Barcelona, Spain.
| | - Maria Guerrero-Torrelles
- Facultat de Medicina i Ciències de la Salut, Universitat Internacional de Catalunya, Barcelona, Spain
| | | | | | - Victòria Clapés-Puig
- Hematology Service, Institut Català d'Oncologia-L'Hospitalet L.-Barcelona, Barcelona, Spain
| | - Jordi Trelis-Navarro
- Palliative Care Service, Institut Català d'Oncologia, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat. Facultat de Medicina i Ciències de la Salut, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Anna Sureda-Balarí
- Hematology Service, Institut Català d'Oncologia-L'Hospitalet L.-Barcelona, Barcelona, Spain
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Foxwell AM, Moyer ME, Casarett DJ, O'Connor NR. Palliative Care Office Hours for Patients with Hematologic Malignancies: An Innovative Model for Symptom Management and Education. J Palliat Med 2017; 20:1148-1151. [DOI: 10.1089/jpm.2017.0091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anessa M. Foxwell
- Palliative Care Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary E. Moyer
- Palliative Care Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J. Casarett
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nina R. O'Connor
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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