Providing Palliative Care to Family Caregivers Throughout the Bone Marrow Transplantation Trajectory: Research and Practice: Partners in Care

Quality of life and symptom burden in hematological cancer patients receiving hematopoietic stem cell transplantation: an observational study at Regional Cancer Centre, India

PURPOSE

Hematopoietic stem cell transplant (HSCT) is an intense form of treatment, resulting in major symptom burden but can prove curative. The quality of life (QOL) is a major endpoint for these patients as the survival rate in them has improved over time. The aim of the study is to assess the QOL and symptom burden of hematological malignancy patients at admission to hospital for HSCT, at 1 month and at 3 months following HSCT.

METHODS

This prospective observational study was done on hematological malignancy patients who were admitted for HSCT in a regional cancer center. The study subjects were assessed by the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT Scale), Edmonton Symptom Assessment Scale-revised (r-ESAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21) at the time of hospital admission for transplantation, on day 30 (~ 1 month) and day100 (~ 3 months) of transplantation.

RESULTS

A total of 68 patients were included in this study. FACT-BMT scores have decreased from baseline (F0) to the first follow-up (F1) and then increased in the third follow-up (F2). The maximum r-ESAS mean score was for tiredness among all other symptoms at F0 as well as at F1 and at F2. The DASS 21 scores for depression, anxiety, and stress were maximum during F1 and minimum during F2.

CONCLUSION

Symptom burden is maximum during the first month of BMT, which improves later and QOL becomes improved with time.

Exploring palliative care provision for recipients of allogeneic hematopoietic stem cell transplantation who relapsed

PURPOSE/OBJECTIVES

To quantify the characteristics of patients who die in the hospital from relapse after allogeneic hematopoietic stem cell transplantation (alloHSCT), explore palliative care integration and end-of-life (EOL) care, and benchmark standards of care.

DESIGN

Retrospective chart review cohort study; a cross-sectional survey design guided a national survey.

SETTING

A chart review was conducted in a large tertiary hospital in Australia. The survey was distributed to leading alloHSCT centers in Australia and New Zealand.

SAMPLE

The chart review sample group was patients in the hematology department who had received an alloHSCT, relapsed, and died in the hospital (N = 40). The survey sample group was the most advanced nurse involved in patient care at each facility (N = 14).

METHODS

A quantitative data collection tool created for chart review, as well as patient notes written by the physician, were examined. The quantitative data collection tool was created for the survey, which was conducted via email or telephone.

MAIN RESEARCH VARIABLES

The chart review measured patient demographics, palliative care integration, EOL care, and symptoms. Survey topics included services available, referrals to palliative care services, EOL discussions, and symptom management.

FINDINGS

About half of the patients were seen by the palliative care service. Many patients experienced severe symptoms in the terminal phase. Survey participants felt EOL discussions were left until the terminal phase. Participants believed early palliative care integration was beneficial for patients and their family.

CONCLUSIONS

The chart review demonstrated late integration of palliative care and poor standards of EOL care. Survey results reiterated this and reflected that nurses are supportive of earlier integration of palliative care and improving EOL care.

IMPLICATIONS FOR NURSING

Palliative care should be integrated earlier, and nursing roles have the potential to address unmet needs for these patients.

Caregiver burden among primary caregivers of patients undergoing peripheral blood stem cell transplantation: a cross sectional study

PURPOSE

This study aimed to identify caregiver burden and influencing factors on the burden in primary caregivers of peripheral blood stem cell transplantation patients within 2-12 months following transplant, indicating early recovery period after discharge.

METHOD

This descriptive cross sectional study was carried out at hematopoietic stem cell transplantation outpatient units of three university hospitals in Turkey. A total of 55 patient and caregiver dyads were recruited and interviewed. The data were collected using questionnaires developed by the researchers and caregiver burden was measured with the Zarit Burden Interview.

RESULTS

The mean score of Zarit Burden Interview was 28.41 (SD = 13.90). Patients' symptoms including nausea and self depreciation feeling were related to greater caregiver burden. Self-depreciation was referred to feeling undervalued. The mean score of the tool was significantly higher in caregivers who have not been educated beyond primary school and also caregivers who had lower income. Caregivers who supported their patients to fulfill physical needs and who did not receive help for meeting patients' psychological needs had statistically more elevated levels of burden. Moreover, the extent of care giving activities undertaken was positively correlated with caregiver burden scores. While positive impact of the care giving process on family relations decreased caregiver burden; negative effect increased the burden.

CONCLUSIONS

This study suggests that caregiver burden of primary caregivers caring for peripheral blood stem cell transplantation patients varies by education, income status, and the extent of care giving activities undertaken. Changes in family ties and relations due to care giving effected caregiver burden.

Design of a cost-effectiveness analysis alongside a randomized trial of transplantation using umbilical cord blood versus HLA-haploidentical related bone marrow in advanced hematologic cancer

BACKGROUND

BMT CTN 1101 is a Phase III randomized controlled trial evaluating the comparative effectiveness of double unrelated umbilical cord blood (dUCB) versus HLA-haploidentical related donor bone marrow (haplo-BM) donor cell sources for blood or bone marrow transplantation (BMT) in patients with hematologic malignancies. Herein, we present the rationale, design and methods of the first cost-effectiveness analysis to be conducted alongside a BMT trial.

METHODS

Consenting patients will provide health insurance information to allow calculation of direct medical costs from reimbursement records, and will provide out-of-pocket costs, time costs and health-related quality of life measures through an online survey. These outcomes will inform a cost-effectiveness analysis comparing dUCB and haplo-BM donor cell sources from patient, payer and societal perspectives.

CONCLUSION

Novel approaches may significantly change the cost, outcomes or availability of BMT. The results of this analysis will be the first to provide a comprehensive evaluation of the comparative effectiveness of these approaches from multiple perspectives.

Patterns of hospice use in patients dying from hematologic malignancies

BACKGROUND

Hospice brings substantial clinical benefits to dying patients and families but is underutilized by patients dying of hematologic malignancies (HM); nationwide, only 2% of HM patients use hospice. There are 70,000 deaths among U.S. patients with hematologic malignancies yearly.

OBJECTIVE

We measured the use and length of stay (LOS) in hospice among patients with HMs at a large academic cancer center.

DESIGN

This was a single center retrospective review of adult patients (≥18 years) with lymphoma, leukemia, myelodysplastic syndrome, aplastic anemia, and multiple myeloma referred for hospice.

MEASUREMENTS

Information included demographics, transplant, hospice type, LOS, and use of "expanded access" services.

RESULTS

Fifty-nine patients were referred to hospice, and 53 utilized hospice services, 25% of 209 HM decedents. Thirty-five received home hospice and 18 used inpatient hospice. The median home hospice LOS was nine days (SD 13) and inpatient hospice six days (SD 10). Nine patients with "expanded access" hospice received only a few blood transfusions, and none received radiation.

CONCLUSIONS

HM patients are referred late or never for hospice services. Studies evaluating earlier integration of palliative and hospice care with usual HM care are warranted. We present a one-page negotiation form that we have found useful in negotiations among HM physicians, hospice medical directors, and payers.

Caring for caregivers: a right way to do it?

PURPOSE OF REVIEW

The support of family caregivers in palliative care is critical and well recognized; yet the fact that caregivers still face significant unmet needs highlights a considerable gap in addressing this issue. Current themes on the caregiving experience in palliative care are presented.

RECENT FINDINGS

The recent literature suggests a shift towards a broader understanding of the caregiving experience in palliative care in terms of better integration of caregivers of patients with noncancer illnesses into palliative care, improved continuity of care among different settings and better integration of guidelines and evidence into practice. Several risk groups and factors of caregiving in palliative care have been identified. The literature review emphasizes a public health approach as an important step in addressing the caregivers' burden. While 'the right way' of supporting caregivers is still to be established, consideration of caregivers' roles as co-providers and co-recipients of care offers numerous implications for research and clinical practice.

SUMMARY

This review demonstrates the need for the development of specific strategies aimed at supporting informal caregivers in caring for their loved ones in different settings and periods of advanced life-threatening illnesses. Open issues in searching for 'the right way' to care for caregivers in palliative care are presented.

The nursing dimension of providing palliative care to children and adolescents with cancer

Palliative care for children and adolescents with cancer includes interventions that focus on the relief of suffering, optimization of function, and improvement of quality of life at any and all stages of disease. This care is most effectively provided by a multidisciplinary team. Nurses perform an integral role on that team by identifying symptoms, providing care coordination, and assuring clear communication. Several basic tenets appear essential to the provision of optimal palliative care. First, palliative care should be administered concurrently with curative therapy beginning at diagnosis and assuming a more significant role at end of life. This treatment approach, recommended by many medical societies, has been associated with numerous benefits including longer survival. Second, realistic, objective goals of care must be developed. A clear understanding of the prognosis by the patient, family, and all members of the medical team is essential to the development of these goals. The pediatric oncology nurse is pivotal in developing these goals and assuring that they are adhered to across all specialties. Third, effective therapies to prevent and relieve the symptoms of suffering must be provided. This can only be accomplished with accurate and repeated assessments. The pediatric oncology nurse is vital in providing these assessments and must possess a working knowledge of the most common symptoms associated with suffering. With a basic understanding of these palliative care principles and competency in the core skills required for this care, the pediatric oncology nurse will optimize quality of life for children and adolescents with cancer.