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Weisse CS, Melekis K, Cheng A, Konda AK, Major A. Mixed-Methods Study of End-of-Life Experiences of Patients With Hematologic Malignancies in Social Hospice Residential Home Care Settings. JCO Oncol Pract 2024; 20:779-786. [PMID: 38306585 DOI: 10.1200/op.23.00534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/28/2023] [Accepted: 12/21/2023] [Indexed: 02/04/2024] Open
Abstract
PURPOSE Hospice is underutilized by patients with hematologic malignancies (HM), and when patients are referred, they are typically more ill, hospitalized, and with shorter length of stay (LOS) than patients with solid tumors (ST), limiting research about home hospice care experiences of patients with HM. In this mixed-methods study, we examined the hospice experiences of patients with HM who died at residential care homes (RCHs), home-based settings in which volunteer caregivers and hospice staff provide end-of-life (EOL) care under the social hospice model. METHODS We queried a registry of 535 hospice patients who died at RCHs between 2005 and 2020 that included quantitative medication administration data as well as qualitative data from hospice intake forms and written volunteer caregiver narratives. Qualitative data were analyzed by collective case study methodology. Quantitative comparisons of LOS and liquid morphine use were performed with matched patients with ST. RESULTS The registry yielded 29 patients with HM, of whom qualitative data were available for 18 patients. Patients with HM exhibited common EOL symptoms (pain, dyspnea, and agitation). Instances of bleeding were low (22%), and notable HM-specific care concerns were described regarding bone fractures, skin integrity, and delirium. Most (78%) experienced good symptom management and peaceful or comfortable deaths. In only one case were symptoms described as severe and poorly managed. Patients with HM had comparable LOS on hospice and at the RCHs to patients with ST, with no group differences in liquid morphine use. CONCLUSION In this registry cohort, most patients with HM achieved good symptom management in home care settings with volunteer caregivers and hospice support. Caregivers may require additional counseling and palliative medications for HM-specific EOL symptoms.
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Affiliation(s)
- Carol S Weisse
- Department of Psychology, Union College, Schenectady, NY
| | - Kelly Melekis
- College of Education and Social Services, University of Vermont, Burlington, VT
| | | | | | - Ajay Major
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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Di Lorenzo S, Mozzi L, Salmaso F, Silvagni C, Soffientini S, Valenti V, Zagonel V. A multicentre survey on the perception of palliative care among health professionals working in haematology. Support Care Cancer 2024; 32:253. [PMID: 38536470 PMCID: PMC10973048 DOI: 10.1007/s00520-024-08452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 03/20/2024] [Indexed: 04/18/2024]
Abstract
PURPOSE Patients with haematologic malignancies have less access to palliative care and are referred later than patients with solid tumours. We developed a survey to investigate this phenomenon, with the intention of analysing palliative care perceptions among health professionals who treat haematology patients and identifying barriers and facilitators to referrals to palliative care services. METHODS This was a multicentre exploratory descriptive web-based survey. A questionnaire was administered to 320 medical and nursing staff members from five Italian haematological units and San Marino's hospital to investigate their perception of palliative care. Quantitative and qualitative analyses were performed. RESULTS A total of 142/320 healthcare professionals completed the survey, achieving a 44% response rate. Most of the respondents supported the integration of haematology and palliative care and were aware of the role of palliative care. Despite this, only half had an in-hospital palliative care team, and only a few had previously attended a specific training course. The majority agreed with palliative care referral when the prognosis was less than 3 months or when the symptoms were incoercible and with blood transfusions even in the last stages of the disease. Many considered the presence of an in-hospital palliative care team or a case manager, as well as structured palliative care training, as fundamental facilitators of palliative care referrals. CONCLUSION These results showed that healthcare professionals in haematology generally hold a favourable attitude and a high interest in integrating palliative care into their patients' care. The low referral rate could depend on clinical, cultural, and organisational issues.
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Affiliation(s)
- Sara Di Lorenzo
- Clinical Hematology and Bone Marrow Transplant and Cellular Therapies Center, Carlo Melzi", Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Lisa Mozzi
- Clinical Hematology, Azienda Ospedaliera Ulss 8 Berica, "St. Bortolo" Hospital, Vicenza, Italy
| | - Flavia Salmaso
- Palliative Care Unit, IRCCS Istituto Oncologico Veneto IOV, Padua, Italy
| | - Claudia Silvagni
- Continuity of Care Center, Istituto Per La Sicurezza Sociale, Cailungo, Republic of San Marino
| | - Silvia Soffientini
- Integrated Home Care Unit, AULLS 6 Euganea - Terme Colli District, Padua, Italy
| | - Vanessa Valenti
- Palliative Care Unit, IRCCS Istituto Romagnolo Per Lo Studio Dei Tumori (IRST), "Dino Amadori", Via P. Maroncelli 40, Meldola, FC, 47014, Italy.
| | - Vittorina Zagonel
- Medical Oncology Unit 1, Department of Clinical and Experimental Oncology, IRCCS Istituto Oncologico Veneto IOV, Padua, Italy
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Binder AF, Hossain A, Doshi R, Vivero A, Gonzalez KM, Gentsch A, Wilde L, Rising KL. Patient and caregiver perceptions of the possibility of home blood transfusions. Transfusion 2024; 64:483-492. [PMID: 38263774 DOI: 10.1111/trf.17728] [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: 10/31/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Patients with hematologic malignancies (HM) often develop transfusion dependence. The patient and caregiver burdens associated with the need for frequent transfusions are high. Home blood transfusions has the potential to reduce these burdens, but is not widely practiced in the United States. We designed a qualitative study to evaluate the patient and caregiver perceptions of the potential for a home blood transfusion program. STUDY DESIGN AND METHODS Eligible patients included Adult (≥18 years) patients who were English speaking and met the definition for transfusion dependence within 3 months of study enrollment. We identified and interviewed eligible participants (patients and caregivers), using a semi-structured interview guide to elicit patient perceptions of the acceptability, barriers, and benefits related to home blood product transfusions. Interviews were audio recorded and transcribed. Results were imported into NVivo 12 (version 12; QSR International, Burlington, VT) for coding and analysis. RESULTS We recruited participants until we reached thematic saturation, which occurred at 29 participants (20 patients, 9 caregivers). Among the 20 patient participants, nine had MDS (45%) and 11 had acute leukemia (55%). Most of the patients (60%) reported getting one transfusion per week. Four themes emerged when the participants discussed their perception regarding the potential of a home blood transfusion program: (1) current in-person experience, (2) caregiver burden, (3) perceptions of home blood transfusions, and (4) interest in participating in a home blood transfusion program. CONCLUSION The concept of home blood transfusions was well received and further research to study its implementation is warranted.
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Affiliation(s)
- Adam F Binder
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alavi Hossain
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Riyana Doshi
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Angelica Vivero
- Department of Pathology and Genomic Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karla Martin Gonzalez
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexzandra Gentsch
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lindsay Wilde
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Mack JW, Cernik C, Uno H, Laurent CA, Fisher L, Xu L, Munneke J, Cannizzaro N, Casperson M, Schwartz CM, Lakin JR, Cooper RM, Altschuler A, Wiener L, Chao CR, Kushi L. Quality of End-of-Life Care Among Adolescents and Young Adults With Cancer. J Clin Oncol 2024; 42:621-629. [PMID: 37890132 DOI: 10.1200/jco.23.01272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 10/29/2023] Open
Abstract
Adolescents, young adults with cancer receive limited psychosocial and spiritual support near death.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Nancy Cannizzaro
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | - Mallory Casperson
- Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Corey M Schwartz
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Joshua R Lakin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert M Cooper
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Chun R Chao
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
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Knight HP, Brennan C, Hurley SL, Tidswell AJ, Aldridge MD, Johnson KS, Banach E, Tulsky JA, Abel GA, Odejide OO. Perspectives on Transfusions for Hospice Patients With Blood Cancers: A Survey of Hospice Providers. J Pain Symptom Manage 2024; 67:1-9. [PMID: 37777022 PMCID: PMC10873003 DOI: 10.1016/j.jpainsymman.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/07/2023] [Accepted: 09/16/2023] [Indexed: 10/02/2023]
Abstract
CONTEXT Patients with blood cancers have low rates of hospice use. While lack of transfusion access in hospice is posited to substantially contribute to these low rates, little is known about the perspectives of hospice providers regarding transfusion access in hospice. OBJECTIVES To characterize hospice providers' perspectives regarding care for patients with blood cancers and transfusions in the hospice setting. METHODS In 2022, we conducted a cross-sectional survey of a sample of hospices in the United States regarding their experience caring for patients with blood cancers, perceived barriers to hospice use, and interventions to increase enrollment. RESULTS We received 113 completed surveys (response rate = 23.5%). Of the cohort, 2.7% reported that their agency always offers transfusions, 40.7% reported sometimes offering transfusions, and 54.9% reported never offering transfusions. In multivariable analyses, factors associated with offering transfusions included nonprofit ownership (OR 5.93, 95% CI, 2.2-15.2) and daily census >50 patients (OR 3.06, 95% CI, 1.19-7.87). Most respondents (76.6%) identified lack of transfusion access in hospice as a barrier to hospice enrollment for blood cancer patients. The top intervention considered as "very helpful" for increasing enrollment was additional reimbursement for transfusions (72.1%). CONCLUSION In this national sample of hospices, access to palliative transfusions was severely limited and was considered a significant barrier to hospice use for blood cancer patients. Moreover, hospices felt increased reimbursement for transfusions would be an important intervention. These data suggest that hospice providers are supportive of increasing transfusion access and highlight the critical need for innovative hospice payment models to improve end-of-life care for patients with blood cancers.
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Affiliation(s)
- Helen P Knight
- Department of Psychosocial Oncology and Palliative Care (H.P.K., J,A,T.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Caitlin Brennan
- Care Dimensions Inc. (C.B., S.L.H.), Boston, Massachusetts; Boston College Connell School of Nursing (C.B.), Chestnut Hill, Massachusetts
| | | | - Anna J Tidswell
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Melissa D Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine (M.D.A.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kimberly S Johnson
- Division of Geriatrics (K.S.J.), Duke University Medical Center, Durham, North Carolina
| | - Edo Banach
- Manatt Health (E.B.), Washington, District of Columbia
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (H.P.K., J,A,T.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A Abel
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies (G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Oreofe O Odejide
- Division of Population Sciences (A.J.T., G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies (G.A.A., O.O.O.), Dana-Farber Cancer Institute, Boston, Massachusetts.
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Shalev Many Y, Shvartzman P, Wolf I, Silverman BG. Place of Death for Israeli Cancer Patients Over a 20-Year Period: Reducing Hospital Deaths, but Barriers Remain. Oncologist 2023; 28:e1092-e1098. [PMID: 37260398 PMCID: PMC10628558 DOI: 10.1093/oncolo/oyad141] [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: 01/11/2023] [Accepted: 04/19/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Cancer remains a leading cause of mortality worldwide. While the main focus of palliative care (PC) is quality of life, the elements that comprise the quality of death are often overlooked. Dying at home, with home-hospice-care (HHC) support, rather than in-hospital, may increase patient satisfaction and decrease the use of invasive measures. We examined clinical and demographic characteristics associated with out-of-hospital death among patients with cancer, which serves as a proxy measure for HHC deaths. METHODS Using death certification data from the Israel Central Bureau of Statistics, we analyzed 209,158 cancer deaths between 1998 and 2018 in Israel including demographic information, cause of death, and place of death (POD). A multiple logistic regression model was constructed to identify factors associated with out-of-hospital cancer deaths. RESULTS Between 1998 and 2018, 69.1% of cancer deaths occurred in-hospital, and 30.8% out-of-hospital. Out-of-hospital deaths increased by 1% annually during the study period. Older patients and those dying of solid malignancies were more likely to die out-of-hospital (OR = 2.65, OR = 1.93, respectively). Likelihood of dying out-of-hospital varied with area of residency; patients living in the Southern district were more likely than those in the Jerusalem district to die out-of-hospital (OR = 2.37). CONCLUSION The proportion of cancer deaths occurring out-of-hospital increased during the study period. We identified clinical and demographic factors associated with POD. Differences between geographical areas probably stem from disparity in the distribution of PC services and highlight the need for increasing access to primary EOL care. However, differences in age and tumor type probably reflect cultural changes and suggest focusing on educating patients, families, and physicians on the benefits of PC.
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Affiliation(s)
| | - Pesach Shvartzman
- Pain and Palliative Care Unit, Department of Family Medicine, Ben Gurion University, Beer Sheva, Israel
| | - Ido Wolf
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Oncology Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Barbara G Silverman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Israel National Cancer Registry, Israel Ministry of Health, Ramat Gan, Israel
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Ernecoff NC, Anhang Price R. Concurrent Care as the Next Frontier in End-of-Life Care. JAMA HEALTH FORUM 2023; 4:e232603. [PMID: 37594744 DOI: 10.1001/jamahealthforum.2023.2603] [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: 08/19/2023] Open
Abstract
Importance Hospice care is a unique type of medical care for people near the end of life and their families, with an emphasis on providing physical and psychological symptom management, spiritual care, and family caregiver support to promote quality of life. However, many people in the US who could benefit from hospice have very short stays or do not enroll at all due to current hospice policy. Changing policy to allow for concurrent availability of disease-directed therapy and hospice care-known as concurrent care-offers an opportunity to increase hospice use and lengths of stay. Observations Under Medicare payment policy, hospices are responsible for covering all costs related to patients' terminal conditions under a per diem rate. This payment structure has led to a de facto requirement that patients forgo costly therapies (including life-prolonging treatments or those with palliative intent) on enrollment in hospice because they are prohibitively expensive. In other countries, in Medicaid for children, and in the Veterans Health Administration in the US, there is greater flexibility in providing hospice services alongside life-prolonging care. Often paired with innovative payment models, concurrent care smooths practical, psychological, and physical care transitions when patient goals prioritize comfort. For example, allowing simultaneous receipt of hospice care and dialysis for people living with end-stage kidney disease-a group with relatively low hospice enrollment-can act as a bridge to hospice and potentially promote longer lengths of stay. Conclusions and Relevance Medicare and health care delivery systems are increasingly testing payment and care delivery models to improve hospice use via concurrent care, offering an important opportunity for innovation to better meet the needs of people living with serious illness and their families.
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Korsos V, Ali A, Malagon T, Khosrow-Khavar F, Thomas D, Sirhan S, Davison K, Assouline S, Cassis C. End of life in haematology: quality of life predictors - retrospective cohort study. BMJ Support Palliat Care 2023:spcare-2023-004218. [PMID: 37068924 DOI: 10.1136/spcare-2023-004218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/15/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVES Haematology patients are more likely to receive high intensity care near end of life (EOL) than patients with solid malignancy. Previous authors have suggested indicators of quality EOL for haematology patients, based on a solid oncology model. We conducted a retrospective chart review with the objectives of (1) determining our performance on these quality EOL indicators, (2) describing the timing of level of intervention (LOI) discussion and palliative care (PC) consultation prior to death and (3) evaluating whether goals of therapy (GOT), PC consultation and earlier LOI discussion are predictors of quality EOL. METHODS We identified patients who died from haematological malignancies between April 2014 and March 2016 (n=319) at four participating McGill University hospitals and performed retrospective chart reviews. RESULTS We found that 17% of patients were administered chemotherapy less than 14 days prior to death, 20% of patients were admitted to intensive care, 14% were intubated and 5% were resuscitated less than 30 days prior to death, 18% of patients received blood transfusion less than 7 days prior to death and 67% of patients died in an acute care setting. LOI discussion and PC consultation occurred a median of 22 days (IQR 7-103) and 9 days (IQR 3-19) before death. Patients with non-curative GOT, PC consultation or discussed LOI were significantly less likely to have high intensity EOL outcomes. CONCLUSIONS In this study, we demonstrate that LOI discussions, PC consults and physician established GOT are associated with quality EOL outcomes for patients with haematological malignancies.
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Affiliation(s)
- Victoria Korsos
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Alla'a Ali
- Rossy Cancer Network, Montreal, Quebec, Canada
| | - Talia Malagon
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Farzin Khosrow-Khavar
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
- Department of Biostatistics and Epidemiology, Rutgers University, New Brunswick, New Jersey, USA
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | | | - Shireen Sirhan
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Kelly Davison
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sarit Assouline
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Chantal Cassis
- Department of Hematology, Jewish General Hospital, Montreal, Quebec, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
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Oh A, Hunt LJ, Ritchie CS, Ornstein KA, Kelley AS, Rajagopalan S, Ankuda CK. Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice? J Palliat Med 2023; 26:385-392. [PMID: 36137095 PMCID: PMC9986009 DOI: 10.1089/jpm.2022.0272] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Medicare home health could be leveraged to care for those near the end of life (EOL), especially for those who cannot access nor desire the Medicare hospice benefit. It is unknown what role home health currently has either preceding or as an alternative to hospice use. Objective: The aim of this study is to compare populations served and visit patterns of Medicare beneficiaries receiving home health/hospice/both near the EOL. Design: Nationally representative cohort study of National Health and Aging Trends Study (NHATS) respondents. Setting/Subjects: A total of 1,057 U.S. decedents in NHATS from 2012 to 2017 with linked Medicare claims were included in this study. Measurements: Measurements included the proportion of decedents who received home health/hospice/both/neither (yes/no) in the last six months of life (EOL) and mean number of visits by discipline (nurse/therapist [physical/occupational speech-language pathologist]/social worker/home health aide) per 30 eligible days at home for home health/hospice/both at the EOL. The primary independent variable was the clinician discipline providing services (nurse/therapist/social worker/aide). Results: In our sample, 19.9% received home health only, 25.8% hospice only, 18.8% both, and 35.6% neither at the EOL. These populations varied in their demographic, region, and clinical characteristics. Decedents who received home health only compared with hospice only were younger (44.1% over age 85 vs. 58.4%), members of a racially/ethnically diverse group (19.7% vs. 10.9%), and with less disability (37.2% required no assistance with activities of daily living vs. 22.7%), all p values <0.05. In adjusted models, those receiving home health versus hospice received similar numbers of visits per 30 days (average 5.4/30 vs. 6.6/30), while those receiving both received more visits (10.5/30). Home health provided more therapy visits, while hospice provided more social work and aide visits. Conclusions: More than one in three Medicare decedents nationwide received home health at the EOL. Home health has the potential to serve a population not reached by hospice and improve the quality of end-of-life care.
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Affiliation(s)
- Anna Oh
- San Francisco VA Health Care System, San Francisco, California, USA
- Department of Social and Behavioral Sciences, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Subashini Rajagopalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
| | - Claire K Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine, New York, New York, USA
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Shaw B, Wood EM, Callum J, McQuilten ZK. Home Delivery: Transfusion Services When and Where They Are Needed. Transfus Med Rev 2022; 36:117-124. [DOI: 10.1016/j.tmrv.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/03/2022] [Accepted: 06/04/2022] [Indexed: 11/16/2022]
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Benini F, Avagnina I, Giacomelli L, Papa S, Mercante A, Perilongo G. Pediatric Palliative Care in Oncology: Basic Principles. Cancers (Basel) 2022; 14:cancers14081972. [PMID: 35454879 PMCID: PMC9031296 DOI: 10.3390/cancers14081972] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary About 4 million children with an oncological disease worldwide require palliative care due to the nature of their condition. The WHO defines pediatric palliative care (PPC) as the prevention and relief of suffering in patients with life-threatening or life-limiting disease and their families. PPC relies on the comprehensive and multidisciplinary management of the child and the family’s physical, psychological, spiritual, and social needs. Importantly, PPC begins at the diagnosis of incurability, or supposed incurability, and continues regardless of whether the patient receives any oncological treatment. As such, PPC is a general approach continuing over the entire disease trajectory, which includes, but is not limited to, end-of-life care. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Abstract About 4 million children with an oncological disease worldwide require pediatric palliative care (PPC) due to the nature of their condition. PPC is not limited to end-of-life care; it is a general approach continuing over the entire disease trajectory, regardless of whether the patient receives any oncological treatment. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Moreover, models for PPC implementation in oncology, end-of-life care, and advanced care planning are discussed.
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Affiliation(s)
- Franca Benini
- Paediatric Palliative Care, Pain Service, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy;
- Correspondence:
| | - Irene Avagnina
- Paediatric Palliative Care, Pain Service, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy;
| | | | | | - Anna Mercante
- Pediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy; (A.M.); (G.P.)
| | - Giorgio Perilongo
- Pediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University of Padua, 35127 Padua, Italy; (A.M.); (G.P.)
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Fan BE, Christopher D, Gallardo CA, Sampath VS. Rationalising red blood cell transfusions in advanced haematological malignancies: a patient-centred approach. THE LANCET. HEALTHY LONGEVITY 2022. [DOI: 10.1016/s2666-7568(21)00277-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Vaughn DM, Johnson PC, Jagielo AD, Topping CEW, Reynolds MJ, Kavanaugh AR, Webb JA, Fathi AT, Hobbs G, Brunner A, O'Connor N, Luger S, Bhatnagar B, LeBlanc TW, El-Jawahri A. Factors Associated with Health Care Utilization at the End of Life for Patients with Acute Myeloid Leukemia. J Palliat Med 2021; 25:749-756. [PMID: 34861118 DOI: 10.1089/jpm.2021.0249] [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: 11/13/2022] Open
Abstract
Background: Patients (≥60 years) with acute myeloid leukemia (AML) often receive intense health care utilization at the end of life (EOL). However, factors associated with their health care use at the EOL are unknown. Methods: We conducted a secondary analysis of 168 deceased patients with AML within the United States. We assessed quality of life (QOL) (Functional-Assessment-Cancer-Therapy-Leukemia), and psychological distress (Hospital-Anxiety-and-Depression Scale [HADS]; Patient-Health-Questionnaire-9 [PHQ-9]) at diagnosis. We used multivariable logistic regression models to examine the association between patient-reported factors and the following outcomes: (1) hospitalizations in the last 7 days of life, (2) receipt of chemotherapy in the last 30 days of life, and (3) hospice utilization. Results: About 66.7% (110/165) were hospitalized in the last 7 days of life, 51.8% (71/137) received chemotherapy in the last 30 days of life, and 40.7% (70/168) utilized hospice. In multivariable models, higher education (odds ratio [OR] = 1.54, p = 0.006) and elevated baseline depression symptoms (PHQ-9: OR = 1.09, p = 0.028) were associated with higher odds of hospitalization in the last seven days of life, while higher baseline QOL (OR = 0.98, p = 0.009) was associated with lower odds of hospitalization at the EOL. Higher baseline depression symptoms were associated with receipt of chemotherapy at the EOL (HADS-Depression: OR = 1.10, p = 0.042). Higher education was associated with lower hospice utilization (OR = 0.356, p = 0.024). Conclusions: Patients with AML who are more educated, with higher baseline depression symptoms and lower QOL, were more likely to experience high health care utilization at the EOL. These populations may benefit from interventions to optimize the quality of their EOL care.
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Affiliation(s)
- Dagny M Vaughn
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Connor Johnson
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Annemarie D Jagielo
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carlisle E W Topping
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Reynolds
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alison R Kavanaugh
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Webb
- Department of Medicine, Division of Hematology/Medical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - Amir T Fathi
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Hobbs
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Brunner
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nina O'Connor
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Selina Luger
- Department of Medicine, Division of Hematology and Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Bhavana Bhatnagar
- Department of Medicine, Section of Hematology/Oncology, West Virginia University Cancer Institute, Wheeling Hospital, Wheeling, West Virginia, USA
| | - Thomas W LeBlanc
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, USA
| | - Areej El-Jawahri
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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14
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Wedding U. Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated care. THE LANCET HEALTHY LONGEVITY 2021; 2:e746-e753. [DOI: 10.1016/s2666-7568(21)00213-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/01/2022]
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15
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Johnson PC, Markovitz NH, Yi A, Newcomb RA, Amonoo HL, Nelson AM, Reynolds MJ, Rice J, Lavoie MW, Odejide OO, Nipp RD, El-Jawahri A. End-of-Life Care for Older Adults with Aggressive Non-Hodgkin Lymphoma. J Palliat Med 2021; 25:728-733. [PMID: 34724798 PMCID: PMC9360173 DOI: 10.1089/jpm.2021.0228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Aggressive non-Hodgkin lymphoma (NHL) commonly affects older adults and is often treated with intensive therapies. Receipt of intensive therapies and absence of a clear transition between the curative and palliative phases of treatment yield prognostic uncertainty and risk for poor end-of-life (EOL) outcomes. However, data regarding the EOL outcomes of this population are lacking. Methods: We conducted a retrospective analysis of adults ≥65 years with aggressive NHL treated with systemic therapy at Massachusetts General Hospital from April 2000 to July 2020 who subsequently died. We abstracted patient and clinical characteristics and EOL outcomes from the medical record. Using multivariable logistic regression, we examined factors associated with hospitalization within 30 days of death and hospice utilization. Results: Among 91 patients (median age = 75 years; 37.4% female), 70.3% (64/91) were hospitalized, 34.1% (31/91) received systemic therapy, and 23.3% (21/90) had an intensive care unit admission within 30 days of death. The rates of palliative care consultation and hospice utilization were 47.7% (42/88) and 39.8% (35/88), respectively. More than half of patients (51.6%, 47/91) died in a hospital or health care facility. In multivariable analysis, elevated lactic acid dehydrogenase was associated with risk of hospitalization within 30 days of death (odds ratio [OR] 3.61, p = 0.014). Palliative care consultation (OR 4.45, p = 0.005) was associated with a greater likelihood of hospice utilization, whereas hypoalbuminemia (OR 0.29, p = 0.026) was associated with a lower likelihood of hospice utilization. Conclusions: Older adults with aggressive NHL often experience high health care utilization and infrequently utilize hospice care at the EOL. Our findings underscore the need for interventions to optimize the quality of EOL care for this population.
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Affiliation(s)
- P Connor Johnson
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Netana H Markovitz
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alisha Yi
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Richard A Newcomb
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hermioni L Amonoo
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ashley M Nelson
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Reynolds
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Rice
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mitchell W Lavoie
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Oreofe O Odejide
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medical Oncology, Center for Lymphoma, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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16
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El-Jawahri A, LeBlanc TW, Kavanaugh A, Webb JA, Jackson VA, Campbell TC, O'Connor N, Luger SM, Gafford E, Gustin J, Bhatnagar B, Walker AR, Fathi AT, Brunner AM, Hobbs GS, Nicholson S, Davis D, Addis H, Vaughn D, Horick N, Greer JA, Temel JS. Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia: A Randomized Clinical Trial. JAMA Oncol 2021; 7:238-245. [PMID: 33331857 PMCID: PMC7747042 DOI: 10.1001/jamaoncol.2020.6343] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Patients with acute myeloid leukemia (AML) receiving intensive chemotherapy experience substantial decline in their quality of life (QOL) and mood during their hospitalization for induction chemotherapy and often receive aggressive care at the end of life (EOL). However, the role of specialty palliative care for improving the QOL and care for this population is currently unknown. OBJECTIVE To assess the effect of integrated palliative and oncology care (IPC) on patient-reported and EOL outcomes in patients with AML. DESIGN, SETTING, AND PARTICIPANTS We conducted a multisite randomized clinical trial of IPC (n = 86) vs usual care (UC) (n = 74) for patients with AML undergoing intensive chemotherapy. Data were collected from January 2017 through July 2019 at 4 tertiary care academic hospitals in the United States. INTERVENTIONS Patients assigned to IPC were seen by palliative care clinicians at least twice per week during their initial and subsequent hospitalizations. MAIN OUTCOMES AND MEASURES Patients completed the 44-item Functional Assessment of Cancer Therapy-Leukemia scale (score range, 0-176) to assess QOL; the 14-item Hospital Anxiety and Depression Scale (HADS), with subscales assessing symptoms of anxiety and depression (score range, 0-21); and the PTSD Checklist-Civilian version to assess posttraumatic stress disorder (PTSD) symptoms (score range, 17-85) at baseline and weeks 2, 4, 12, and 24. The primary end point was QOL at week 2. We used analysis of covariance adjusting and mixed linear effect models to evaluate patient-reported outcomes. We used Fisher exact test to compare patient-reported discussion of EOL care preferences and receipt of chemotherapy in the last 30 days of life. RESULTS Of 235 eligible patients, 160 (68.1%) were enrolled; of the 160 participants, the median (range) age was 64.4 (19.7-80.1) years, and 64 (40.0%) were women. Compared with those receiving UC, IPC participants reported better QOL (adjusted mean score, 107.59 vs 116.45; P = .04), and lower depression (adjusted mean score, 7.20 vs 5.68; P = .02), anxiety (adjusted mean score, 5.94 vs 4.53; P = .02), and PTSD symptoms (adjusted mean score, 31.69 vs 27.79; P = .01) at week 2. Intervention effects were sustained to week 24 for QOL (β, 2.35; 95% CI, 0.02-4.68; P = .048), depression (β, -0.42; 95% CI, -0.82 to -0.02; P = .04), anxiety (β, -0.38; 95% CI, -0.75 to -0.01; P = .04), and PTSD symptoms (β, -1.43; 95% CI, -2.34 to -0.54; P = .002). Among patients who died, those receiving IPC were more likely than those receiving UC to report discussing EOL care preferences (21 of 28 [75.0%] vs 12 of 30 [40.0%]; P = .01) and less likely to receive chemotherapy near EOL (15 of 43 [34.9%] vs 27 of 41 [65.9%]; P = .01). CONCLUSIONS AND RELEVANCE In this randomized clinical trial of patients with AML, IPC led to substantial improvements in QOL, psychological distress, and EOL care. Palliative care should be considered a new standard of care for patients with AML. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02975869.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - Alison Kavanaugh
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Jason A Webb
- Duke University School of Medicine, Durham, North Carolina
| | - Vicki A Jackson
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | - Amir T Fathi
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Andrew M Brunner
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Gabriela S Hobbs
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Showly Nicholson
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Debra Davis
- Duke University School of Medicine, Durham, North Carolina
| | | | | | - Nora Horick
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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17
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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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18
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LeBlanc TW. Improving end-of-life care for patients with leukemia: is inpatient death the right measure? Leuk Lymphoma 2020; 61:2546-2548. [DOI: 10.1080/10428194.2020.1838510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Thomas W. LeBlanc
- Duke Cancer Institute, Durham, NC, USA
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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19
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Guan JHC. Tailoring care for patients with haematological malignancies. Lancet Haematol 2020; 7:e559. [PMID: 32735832 DOI: 10.1016/s2352-3026(20)30206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/03/2020] [Indexed: 06/11/2023]
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