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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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Kim DH, Youk J, Byun JM, Koh Y, Hong J, Kim TM, Kim I, Yoon SS, Yoo SH, Shin DY. Effects of tertiary palliative care on the pattern of end-of-life care in patients with hematologic malignancies in Korea. Eur J Haematol 2024; 112:743-755. [PMID: 38154958 DOI: 10.1111/ejh.14165] [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: 10/04/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Patients with hematologic malignancies (HMs) often face challenges in accessing palliative care (PC) and receiving quality end-of-life (EOL) care. We examined factors associated with referrals to tertiary PC and the effects of tertiary PC on EOL care in patients with HMs. METHOD We included patients with HMs who were admitted to a university-affiliated hospital and died during hospitalization between January 2018 and December 2021. We investigated the receipt of PC consultations, patient characteristics, and EOL care indicators. RESULTS Overall, 487 patients were included in the analysis, with 156 (32%) undergoing PC consultation. Sex, residence, disease status, and admission purpose were factors associated with the likelihood of PC consultation, and there has been an increasing trend in the frequency of consultations in recent cases. A higher proportion of patients who received PC completed advance statements and life-sustaining treatment documents. Patients who received PC had lower rates of aggressive EOL care, including chemotherapy and intensive care unit admission, than those who did not receive PC. Notably, PC reduced the number of blood transfusions. CONCLUSION Tertiary PC aims to reduce aggressive EOL care through patient-centered goal-of-care discussions. Therefore, there is an imperative need for concerted efforts toward seamless integration of PC.
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Affiliation(s)
- Dong Hyun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeonghwan Youk
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae Min Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
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Gebel C, Ditscheid B, Meissner F, Slotina E, Kruschel I, Marschall U, Wedding U, Freytag A. Utilization and quality of palliative care in patients with hematological and solid cancers: a population-based study. J Cancer Res Clin Oncol 2024; 150:191. [PMID: 38607376 PMCID: PMC11014814 DOI: 10.1007/s00432-024-05721-6] [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: 02/19/2024] [Accepted: 03/22/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Palliative care (PC) contributes to improved end-of-life care for patients with hematologic malignancies (HM) and solid tumors (ST) by addressing physical and psychological symptoms and spiritual needs. Research on PC in HM vs. ST patients is fragmented and suggests less use. METHODS We analyzed claims data of all deceased members of a large German health insurance provider for the year before death. First, we analyzed the frequency and the beginning of different types of PC and compared patients with HM vs. ST. Second, we analyzed the adjusted impact of PC use on several end-of-life quality outcomes in patients with HM vs. ST. We performed simple and multiple (logistic) regression analysis, adjusted for relevant covariates, and standardized for age and sex. RESULTS Of the 222,493 deceased cancer patients from 2016 to 2020, we included 209,321 in the first analysis and 165,020 in the second analysis. Patients with HM vs. ST received PC less often (40.4 vs. 55.6%) and later (34 vs. 50 days before death). PC use significantly improved all six quality indicators for good end-of-life care. HM patients had worse rates in five of the six indicators compared with ST patients. Interaction terms revealed that patients with ST derived greater benefit from PC in five of six quality indicators than those with HM. CONCLUSION The data highlight the need to integrate PC more often, earlier, and more effectively into the care of patients with HM.
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Affiliation(s)
- Cordula Gebel
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany.
- Comprehensive Cancer Center Central Germany (CCCG), Jena, Deutschland.
| | - Bianka Ditscheid
- Institute of General Practice, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
| | - Franziska Meissner
- Institute of General Practice, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
| | - Ekaterina Slotina
- Institute of General Practice, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
| | - Isabel Kruschel
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Jena, Deutschland
| | | | - Ullrich Wedding
- Department of Palliative Care, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Comprehensive Cancer Center Central Germany (CCCG), Jena, Deutschland
| | - Antje Freytag
- Institute of General Practice, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
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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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Paim Miranda DL, Orathes Ponte Silva AM, Pereira Ferreira D, Teixeira da Silva L, Lins-Kusterer L, de Queiroz Crusoé E, Vieira Lima MB, Aurélio Salvino M. Variability in the perception of palliative care and end-of-life care among hematology professionals from the same reference center in Bahia, Brazil: A descriptive cross-sectional study. SAO PAULO MED J 2024; 142:e2023225. [PMID: 38422243 PMCID: PMC10885630 DOI: 10.1590/1516-3180.2023.0255.r1.29112023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/31/2023] [Accepted: 11/29/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND There are several illness-specific cultural and system-based barriers to palliative care (PC) integration and end-of-life (EOL) care in the field of oncohematology. OBJECTIVES This study aimed to investigate the variability in the perceptions of PC and EOL care. DESIGN AND SETTING A cross-sectional study was conducted in the Hematology Division of our University Hospital in Salvador, Bahia, Brazil. METHODS Twenty physicians responded to a sociodemographic questionnaire and an adaptation of clinical questionnaires used in previous studies from October to December 2022. RESULTS The median age of the participants was 44 years, 80% of the participants identified as female, and 75% were hematologists. Participants faced a hypothetical scenario involving the treatment of a 65-year-old female with a poor prognosis acute myeloid leukemia refractory to first-line treatment. Sixty percent of the participants chose to follow other chemotherapy regimens, whereas 40% opted for PC. Next, participants considered case salvage for the patient who developed septic shock following chemotherapy and were prompted to choose their most probable conduct, and the conduct they thought would be better for the patient. Even though participants were from the same center, we found a divergence from the most probable conduct among 40% of the participants, which was due to personal convictions, legal aspects, and other physicians' reactions. CONCLUSIONS We found considerable differences in the perception of PC and EOL care among professionals, despite following the same protocols. The study also demonstrated variations between healthcare professionals' beliefs and practices and persistent historical tendencies to prioritize aggressive interventions.
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Affiliation(s)
- Diego Lopes Paim Miranda
- MD. MSc student, Postgraduate Program in Medicine and Health, Professor Edgard Santos University Hospital, Medical School, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - Alini Maria Orathes Ponte Silva
- MD. MSc student, Postgraduate Program in Medicine and Health, Professor Edgard Santos University Hospital, Medical School, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - David Pereira Ferreira
- Medicine Student, Medical School, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - Laís Teixeira da Silva
- MD. MSc student, Postgraduate Program in Medicine and Health, Professor Edgard Santos University Hospital, Medical School, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - Liliane Lins-Kusterer
- PhD. Dental Surgeon, Professor, Postgraduate Program in Medicine and Health, Department of Preventive and Social Medicine Medical School, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - Edvan de Queiroz Crusoé
- MD, PhD. Hospital Universitário Professor Edgard Santos (HUPES), Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - Marianna Batista Vieira Lima
- MD. Physician, Hospital Universitário Professor Edgard Santos (HUPES), Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
| | - Marco Aurélio Salvino
- MD, PhD. Associate Professor, Postgraduate Program in Medicine and Health, Professor Edgard Santos University Hospital, Medical School, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil
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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:OP2300534. [PMID: 38306585 DOI: 10.1200/op.23.00534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Malakian A, Rodin G, Widger K, Ali R, Mahendiran AE, Mayo SJ. Experience of Care Among Adults With Acute Leukemia Near the End of Life: A Scoping Review. J Palliat Med 2024; 27:255-264. [PMID: 37738328 DOI: 10.1089/jpm.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Abstract
Background: Acute leukemia is a cancer of the blood and bone marrow with a high symptom burden and a high mortality rate in adults. The quality of end-of-life care among this patient population is deemed to be low based on health care administrative data, though the patient experience is not included in this evaluation. Objective: This scoping review aims at exploring and mapping the current research literature on the experience of care among adults with incurable acute leukemia near the end of life. Design: The JBI framework guided our scoping review, and the protocol was prospectively registered in the Open Science Forum. Results: A total of 5661 unique articles were screened for title and abstract, and 44 were selected for full text. After a manual search, five studies published in seven articles were selected for data extraction, including three qualitative and two quantitative studies. Two studies used family caregivers as patient proxies, two studies engaged patients directly, whereas one study obtained data from patients and family caregivers. Patient care in acute settings was reported in all studies, with most patients dying in acute care settings. Patients and family caregivers often valued an open and honest approach, with sufficient time for dialogue with their providers. Discussions about prognosis, palliative care, and hospice care were often late or incomplete. The medicalization of end-of-life care, including intensive care unit admissions and invasive medical procedures, were viewed as the norm by some providers, though perceived as distressing for both patients and their loved ones. Conclusions: Adults with acute leukemia face significant challenges in accessing high-quality end-of-life care brought about by the complex nature of their disease and its treatment. A systematic exploration of the end-of-life experience among these patients through direct patient engagement or by way of patient reporting proxies is needed.
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Affiliation(s)
- Argin Malakian
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Gary Rodin
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care, University Health Network (UHN), Toronto, Ontario, Canada
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Lifespan Program, ICES, Toronto, Ontario, Canada
| | - Ridwaanah Ali
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Angela E Mahendiran
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
| | - Samantha J Mayo
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, Ontario, Canada
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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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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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Burstein R, Aviv A, Even-Zohar NG, Nachmias B, Haran A, Braun M, Rottenberg Y, Shaulov A. Comparing end-of-life care of hematologic malignancy versus solid tumor patients in a tertiary care center. Eur J Haematol 2023; 111:528-535. [PMID: 37385825 DOI: 10.1111/ejh.14035] [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: 03/13/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To compare end-of-life (EOL) care for solid tumor and hematologic malignancy (HM) patients. METHODS We collected data on the last 100 consecutive deceased HM and 100 consecutive deceased solid tumor patients who died prior to June 1st 2020, treated at a single center. We compared demographic parameters, cause of death as ascertained by review of medical records by two independent investigators, and EOL quality indicators including: place of death, use of chemotherapy or targeted/biologic treatment, emergency department visits as well as hospital, inpatient hospice and Intensive Care Unit admissions and the time spent as inpatient over the last 30 days of life; mechanical ventilation and use of blood products during the last 14 days of life. RESULTS In comparison with solid tumor patients, HM patients more commonly died from treatment complications (13% vs. 1%) and unrelated causes (16% vs. 2%, p < .001 for all comparisons). HM patients died more frequently than solid tumor patients in the intensive care unit (14% vs. 7%) and the emergency department (9% vs. 0%) and less frequently in hospice (9% vs. 15%, p = .005 for all comparisons). In the 2 weeks prior to death HM patients were more likely than solid tumor patients to undergo mechanical ventilation (14% vs. 4%, p = .013), receive blood (47% vs. 27%, p = .003) and platelet transfusions (32% vs. 7%, p < .001); however, no statistical difference was found in use of either of chemotherapy (18% vs. 13%, p = .28) or targeted treatment (10% vs. 5%, p = .16). CONCLUSIONS HM patients were more likely than solid tumor patients to undergo aggressive measures at EOL. Rarity of HM deaths, frequently caused by complications of treatment and unrelated causes, may affect treatment choices at EOL.
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Affiliation(s)
- Rachel Burstein
- School of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Aviv
- Department of Hematology, HaEmek Medical Center, Afula, Israel
| | - Noa Gross Even-Zohar
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Boaz Nachmias
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Arnon Haran
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Braun
- Breast Oncology Unit, Sharett Institute of Oncology, Hadassah Medical Center, Jerusalem, Israel
- School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
| | - Yakir Rottenberg
- Department of Oncology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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11
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Pralong A, Herling M, Holtick U, Scheid C, Hellmich M, Hallek M, Pauli B, Reimer A, Schepers C, Simon ST. Developing a supportive and palliative care intervention for patients with allogeneic stem cell transplantation: protocol of a multicentre mixed-methods study (allo-PaS). BMJ Open 2023; 13:e066948. [PMID: 37652589 PMCID: PMC10476131 DOI: 10.1136/bmjopen-2022-066948] [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: 07/26/2022] [Accepted: 07/27/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Although allogeneic stem cell transplantation (allo-SCT) is a curative treatment for many haematological malignancies, it is often associated with a high morbidity and mortality. Yet, little is known about the needs for supportive and palliative care among allo-SCT recipients. Moreover, targeted interventions that reduce symptom burden and suffering are still lacking. The present study aims to inform a supportive-palliative care intervention for patients with allo-SCT and their informal carers by exploring their experience and assessing their needs, especially their existential concerns, regarding four research topics: symptom burden and quality of life; coexistence of a chance for cure and a relevant risk of dying; change in goals of care; dying phase. METHODS AND ANALYSIS This is a descriptive mixed-methods study in progress with a convergent parallel design. Data on the four research topics will be collected and analysed separately in three steps: (1) qualitative semi-structured interviews among 20 patients, 20 informal carers and 12 healthcare providers (HCPs) and focus groups among 12-24 HCPs; (2) a quantitative cross-sectional survey with validated questionnaires and self-developed questions among 100 patients, 100 informal carers and 50 HCPs; (3) a retrospective case analysis of all deceased patients who underwent an allo-SCT between 2010 and 2019, with collection of quantitative and qualitative data. The qualitative and quantitative data sets will be finally merged for comparison and interpretation. Results will serve to develop a supportive-palliative care intervention. ETHICS AND DISSEMINATION The Ethics Commission of the Faculty of Medicine of the University of Cologne approved this study (20-1370_2). The study results will be published in peer-review journals, be presented at congresses and will be translated into clinical practice through the development of the palliative-supportive care intervention. TRIAL REGISTRATION NUMBER DRKS00027290 (German Clinical Trials Register).
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Affiliation(s)
- Anne Pralong
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Marco Herling
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Department of Hematology, Cellular Therapy, and Hemostaseology, Faculty of Medicine, University of Leipzig, Leipzig, Sachsen, Germany
- Department of Internal Medicine I, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Udo Holtick
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Department of Internal Medicine I, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Christoph Scheid
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Department of Internal Medicine I, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Michael Hallek
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Department of Internal Medicine I, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Berenike Pauli
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Alinda Reimer
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Carolin Schepers
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Steffen T Simon
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Centre for Integrated Oncology Aachen-Bonn-Cologne-Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Centre for Health Services Research, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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12
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Gebel C, Basten J, Kruschel I, Ernst T, Wedding U. Knowledge, feelings, and willingness to use palliative care in cancer patients with hematologic malignancies and solid tumors: a prospective, cross-sectional study in a comprehensive cancer center in Germany. Support Care Cancer 2023; 31:445. [PMID: 37410174 DOI: 10.1007/s00520-023-07914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE Patients with hematologic malignancies (HM) receive palliative care (PC) less often and later than patients with solid tumors (ST). Patients' lack of knowledge about PC and negative feelings about PC are barriers to their willingness to use PC. Is there a difference between patients with HM and ST in their knowledge and willingness to use PC? METHODS Two hundred ten patients (85 HM, 125 ST) from an oncology day clinic at a university hospital participated in this cross-sectional, questionnaire-based survey. RESULTS Patients with HM and ST had high knowledge and mainly positive feelings about PC. More than half of the patients answered that they would feel reassured by the use of PC, and one-third would feel anxious or hopeless. The majority of patients (58.3%) were willing to use PC. There are no significant differences between patients with HM and ST. In multiple regression analysis, perceived chance of cure and feelings of reassurance and anxiety are associated with willingness to use PC, but not with the HM/ST disease group. More than half (53.9%) of the participants would like the treating physician to choose the timing of a discussion about PC. CONCLUSION Our study shows a high level of knowledge and relatively positive feelings of patients about PC, with no differences between patients with HM or ST. They expect their treating physician to initiate communication about PC. Communication should include the patient's feelings about PC and their chances of a cure.
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Affiliation(s)
- Cordula Gebel
- Department of Palliative Care, Jena University Hospital, Jena, Germany.
| | - Judith Basten
- Department of Palliative Care, Jena University Hospital, Jena, Germany
| | - Isabel Kruschel
- Department of Palliative Care, Jena University Hospital, Jena, Germany
| | - Thomas Ernst
- University Tumor Center, Jena University Hospital, Jena, Germany
| | - Ulrich Wedding
- Department of Palliative Care, Jena University Hospital, Jena, Germany
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13
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Kokaji M, Imoto N, Watanabe M, Suzuki Y, Fujiwara S, Ito R, Sakai T, Yamamoto S, Sugiura I, Kurahashi S. End-of-Life Care of Acute Myeloid Leukemia Compared with Aggressive lymphoma in Patients Who Are Eligible for Intensive Chemotherapy: An Observational Study in a Japanese Community Hospital. Palliat Med Rep 2023; 4:71-78. [PMID: 36960234 PMCID: PMC10029750 DOI: 10.1089/pmr.2022.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/25/2023] Open
Abstract
Background Patients with hematological malignancies (HMs) are reported to receive more aggressive care at the end of life (EOL) than patients with solid tumors. However, the reasons behind this occurrence are not fully understood. Objectives To examine whether the care at EOL for HMs is mainly because of the disease characteristics or hematologists' attitudes and systems of care, we compared the EOL care of patients with acute myeloid leukemia (AML) and diffuse large B cell lymphoma (DLBCL). Design We retrospectively analyzed the EOL care of patients with AML and DLBCL younger than 80 years who were receiving combination chemotherapy at a city hospital in Japan. Results Fifty-nine patients with AML and 65 with DLBCL were included. Those with AML received chemotherapy more often within their last 30 days (48% vs. 19%, p < 0.001) and 14 days (37% vs. 1.5%, p < 0.001) of life, and consulted the palliative team less frequently (5.3% vs. 29%, p < 0.001). In the last 3 years, the mortality rate in hematological wards decreased from 74% to 29% in the DLBCL group, but only from 95% to 90% in the AML group. In multivariate analysis, AML (odds ratio [OR] 0.065) and death before 2018 (OR, 0.077) were significant factors associated with reduced referrals to specialized palliative teams. Conclusion Patients with AML tend to have lesser access to specialized palliative care and fewer options for their place of death than those with DLBCL. Detailed EOL care plans are needed for these patients, considering the characteristics of the disease.
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Affiliation(s)
- Masato Kokaji
- Department of Postgraduate Clinical Training Center, Toyohashi Municipal Hospital, Toyohashi, Japan
- Department of Obstetrics and Gynecology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Naoto Imoto
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
- Address correspondence to: Naoto Imoto, MD, PhD, Department of Hematology and Oncology, Toyohashi Municipal Hospital, 50 Aza Hachiken Nishi, Aotake–Cho, Toyohashi, Aichi, Japan.
| | - Miki Watanabe
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Yutaro Suzuki
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Shinji Fujiwara
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
- Department of Hematology, Nagoya Graduate School of Medicine, Nagoya, Japan
| | - Rie Ito
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Toshiyasu Sakai
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Satomi Yamamoto
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Isamu Sugiura
- Department of Internal Medicine, Toyohashi Hematology Oncology Clinic, Toyohashi, Japan
| | - Shingo Kurahashi
- Department of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
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Ferreira APS, Ferraz LFDM, de Melo Campos P, Teixeira PDMN. "There's nothing left to do!": the interface between Hematology and Palliative Care. Hematol Transfus Cell Ther 2023; 45:134-136. [PMID: 36681620 PMCID: PMC9938486 DOI: 10.1016/j.htct.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/13/2022] [Indexed: 02/06/2023] Open
Affiliation(s)
- Amanda Pifano Soares Ferreira
- OC Oncoclínicas Hematológica, Belo Horizonte, MG, Brazil; Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, MG, Brazil.
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15
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Salins N, Hughes S, Preston N. Presuppositions, cost–benefit, collaboration, and competency impacts palliative care referral in paediatric oncology: a qualitative study. Palliat Care 2022; 21:215. [DOI: 10.1186/s12904-022-01105-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
Abstract
Background
Although a significant proportion of children with cancer need palliative care, few are referred or referred late, with oncologists and haematologists gatekeeping the referral process. We aimed to explore the facilitators and barriers to palliative care referral.
Methods
Twenty-two paediatric oncologists and haematologists were purposively recruited and interviewed. Data were analysed using reflexive thematic analysis. Findings were interpreted using the critical realist paradigm.
Results
Four themes were generated. 1) Oncologists expressed concern about the competency of palliative care teams. Palliative care often symbolised therapeutic failure and abandonment, which hindered referral. Trustworthy palliative care providers had clinical competence, benevolence, and knowledge of oncology and paediatrics. 2) Making a palliative care referral was associated with stigma, navigating illness-related factors, negative family attitudes and limited resources, impeding palliative care referral. 3) There were benefits to palliative care referral, including symptom management and psychosocial support for patients. However, some could see interactions with the palliative care team as interference hindering future referrals. 4) Suggested strategies for developing an integrated palliative care model include evident collaboration between oncology and palliative care, early referral, rebranding palliative care as symptom control and an accessible, knowledgeable, and proactive palliative care team.
Conclusion
Presuppositions about palliative care, the task of making a referral, and its cost-benefits influenced referral behaviour. Early association with an efficient rebranded palliative care team might enhance integration.
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16
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Burghi G, Metaxa V, Pickkers P, Soares M, Rello J, Bauer PR, van de Louw A, Taccone FS, Loeches IM, Schellongowski P, Rusinova K, Antonelli M, Kouatchet A, Barratt-Due A, Valkonen M, Pène F, Mokart D, Jaber S, Azoulay E, De Jong A. End of life decisions in immunocompromised patients with acute respiratory failure. J Crit Care 2022; 72:154152. [PMID: 36137351 DOI: 10.1016/j.jcrc.2022.154152] [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: 07/29/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify patient, disease and organizational factors associated with decisions to forgo life-sustaining therapies (DFLSTs) in critically ill immunocompromised patients admitted to the intensive care unit (ICU) for acute respiratory failure. MATERIAL AND METHODS We performed a secondary analysis of the international EFRAIM prospective study, which enrolled 1611 immunocompromised patients with acute respiratory failure admitted to 68 ICUs in 16 countries between October 2015 and June 2016. Multivariate logistic analysis was performed to identify independent predictors of DFLSTs. RESULTS The main causes of immunosuppression were hematological malignancies (50%) and solid tumor (38%). Patients had a median age of 63 yo (54-71). A pulmonologist was involved in the patient management in 38% of cases. DFLSTs had been implemented in 28% of the patients. The following variables were independently associated with DFLSTs: 1) patient-related: older age (OR 1.02 per one year increase, 95% confidence interval(CI) 1.01-1.03,P < 0.001), poor performance status (OR 2.79, 95% CI 1.98-3.93, P < 0.001); 2) disease-related: shock (OR 2.00, 95% CI 1.45-2.75, P < 0.001), liver failure (OR 1.59, 95% CI 1.14-2.21, P = 0.006), invasive mechanical ventilation (OR 1.79, 95% CI 1.31-2.46, P < 0.001); 3) organizational: having a pulmonologist involved in patient management (OR 1.85, 95% CI 1.36-2.52, P < 0.001), and the presence of a critical care outreach services (OR 1.63, 95% CI 1.11-2.38, P = 0.012). CONCLUSIONS A DFLST is made in one in four immunocompromised patient admitted to the ICU for acute respiratory failure. Involving a pulmonologist in patient's management is associated with less non beneficial care.
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Affiliation(s)
- Gaston Burghi
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | | | - Peter Pickkers
- The Department of Intensive Care Medicine (710), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marcio Soares
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | - Jordi Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andry van de Louw
- Penn State University College of Medicine, Division of Pulmonary and Critical Care, Hershey, PA, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | | | - Katerina Rusinova
- Department of Anesthesiology and Intensive Care Medicine and Institute for Medical Humanities, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Massimo Antonelli
- Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, France
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Miia Valkonen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki 00014, Finland
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University Paris Descartes, Paris, France
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis and Paris Diderot Sorbonne University, 1 avenue Claude Vellefaux, cedex 10 75475, Paris
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France.
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17
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McInturf G, Younger K, Sanchez C, Walde C, Abdallah AO, Ahmed N, Shune L, Sborov DW, Godara A, McClune B, Sinclair CT, Mohyuddin GR. Palliative care utilization, transfusion burden, and end-of-life care for patients with multiple myeloma. Eur J Haematol 2022; 109:559-565. [PMID: 36054450 DOI: 10.1111/ejh.13843] [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: 05/20/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Despite treatment advances, multiple myeloma (MM) remains a significant source of morbidity and mortality. We aimed to examine specialist palliative care (SPC) involvement and end-of-life care for patients with MM. METHODS We assessed all deceased patients with a diagnosis of MM who received care at a single institution from January 2010 to December 2019 and assessed SPC involvement. RESULTS We reviewed 456 deceased patients. Overall, 207 patients (45.4%) received SPC visits by clinicians during their disease, and 153 (33.5%) were on MM treatment in the month before death. Median time from SPC consultation to death was 1 month, with 42 (9.2%) of patients receiving SPC visits 6 or more months before death. Amongst the patients for which a place of death was reported (351), 117 (33.3%) died in the acute care setting. Outpatient SPC did not correlate with a reduction of death in the acute care setting. In the group of patients who received outpatient SPC, 22/84 (26.2%) died in an acute care setting, whereas 95/267 (35.5%) patients who did not receive outpatient SPC also died in an acute care setting, (p = .11). CONCLUSION In our analysis of the entire trajectory of the MM patient experience from diagnosis to death, we found low rates of SPC involvement and a significant proportion of patients receiving aggressive care at end-of-life. While there is no clear correlation that SPC involvement impacted the rate of acute care deaths or decreased utilization of MM treatment in the last month of life, further prospective research on optimal utilization of SPC is required.
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Affiliation(s)
- Geoffrey McInturf
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Kimberly Younger
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Courtney Sanchez
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Charles Walde
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Al-Ola Abdallah
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Nausheen Ahmed
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Leyla Shune
- School of Medicine, University of Kansas Medical Center, Lawrence, Kansas, USA
| | - Douglas W Sborov
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| | - Amandeep Godara
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| | - Brian McClune
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Ghulam Rehman Mohyuddin
- Division of Hematology, Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA
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18
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Ebert RPC, Magnus MM, Toro P, Manoel FG, Costa FF, Olalla Saad ST, de Melo Campos P. Hematologic Malignancies Patients Face High Symptom Burden and Are Lately Referred to Palliative Consultation: Analysis of a Single Center Experience. Am J Hosp Palliat Care 2022:10499091221132285. [PMID: 36205034 DOI: 10.1177/10499091221132285] [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: 11/15/2022] Open
Abstract
Although hematologic neoplasms have been on the vanguard of cancer therapies that led to notable advances in therapeutic efficacy, many patients face significant symptom burden, which make them eligible for early palliative care (PC) integration. However, previous reports demonstrated that hematological malignancies receive more aggressive care at the end-of-life and are less likely to receive care from specialist palliative services compared to solid tumors. Our aim was to characterize symptom burden, performance status and clinical characteristics of a cohort of hematologic malignancies patients referred to PC outpatient consultation, according to their diagnosis. Fifty-nine hematological malignancies patients referred to PC consultation between January 2018 and September 2021 were included. Clinical and laboratory data were evaluated retrospectively by medical charts analysis. Patients exhibited high ESAS and reduced PPS scores at the time of PC referral. Acute leukemia and multiple myeloma patients had the highest symptom burden scores; in spite of this, median time from the first PC consultation until death was only 3 and 4 months, respectively. In conclusion, we identified that hematologic neoplasms patients are highly symptomatic and are frequently referred to PC in end stages of their disease.
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Affiliation(s)
- Raissa P C Ebert
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
| | - Mariana M Magnus
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
| | - Pedro Toro
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
| | - Fabiana G Manoel
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
| | - Fernando F Costa
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
| | - Sara T Olalla Saad
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
| | - Paula de Melo Campos
- Hematology and Transfusion Medicine Center - University of Campinas/Hemocentro- UNICAMP, Campinas, Brazil
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Shaulov A, Aviv A, Alcalde J, Zimmermann C. Early integration of palliative care for patients with haematological malignancies. Br J Haematol 2022; 199:14-30. [PMID: 35670630 PMCID: PMC9796711 DOI: 10.1111/bjh.18286] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/30/2022] [Accepted: 05/17/2022] [Indexed: 01/07/2023]
Abstract
Early palliative care (EPC) significantly improves quality of life, symptoms, and satisfaction with care for patients with advanced cancer. International organizations have recognized and promoted the role of palliative care as a distinct specialty, advocating its involvement throughout the cancer trajectory. Although patients with haematologic malignancies (HMs) have a comparable symptom burden to patients with solid tumours, they face multiple barriers to EPC integration. In this review, we discuss these barriers, present updated evidence from clinical trials of EPC in HMs and propose models to support EPC integration into care for patients with HMs.
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Affiliation(s)
- Adir Shaulov
- Department of HaematologyHadassah Medical CenterJerusalemIsrael,Faculty of MedicineHebrew University of JerusalemIsrael
| | - Ariel Aviv
- Department of HaematologyHaEmek Medical CenterAfulaIsrael
| | - Jacqueline Alcalde
- Department of Supportive Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada,Department of MedicineUniversity of TorontoTorontoOntarioCanada,Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
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Kayastha N, LeBlanc TW. Palliative care for patients with hematologic malignancies: are we meeting patients' needs early enough? Expert Rev Hematol 2022; 15:813-820. [PMID: 36062508 DOI: 10.1080/17474086.2022.2121696] [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: 11/04/2022]
Abstract
INTRODUCTION Palliative care for patients with cancer, and more recently for patients with hematologic malignancies, has increasingly been shown to be beneficial, with mounting evidence pointing to its vast benefits both to patients and caregivers. Despite this, there is a significant gap in integration of palliative care into usual cancer care for patients with hematologic malignancies. AREAS COVERED In this paper, we will define palliative care and discuss its benefits broadly for patients with hematologic malignancies. We will then discuss the late access to palliative care, the unmet needs in this patient population, and some of the barriers to access to palliative care. EXPERT OPINION With all this information and the clear benefit for early integrated palliative care for patients with hematologic malignancies, there is a need for novel models of palliative care and cancer care integration. Given the various needs of patients with different hematologic malignancies, we propose how palliative care can meet the unique needs of patients with hematologic malignancy by disease subtype.
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Affiliation(s)
- Neha Kayastha
- Department of Medicine, Duke University School of Medicine
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine.,Duke Cancer Institute
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21
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Ferraz LFDM, Ferreira APS, Guimarães TVV, de Melo Campos P. Early integration of palliative care in hematology: an urgency for patients, a challenge for physicians. Hematol Transfus Cell Ther 2022; 44:567-573. [PMID: 35989250 PMCID: PMC9605907 DOI: 10.1016/j.htct.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/11/2022] [Accepted: 06/24/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Objective and method Results and conclusion
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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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Hart NH, Crawford-Williams F, Crichton M, Yee J, Smith TJ, Koczwara B, Fitch MI, Crawford GB, Mukhopadhyay S, Mahony J, Cheah C, Townsend J, Cook O, Agar MR, Chan RJ. Unmet supportive care needs of people with advanced cancer and their caregivers: a systematic scoping review. Crit Rev Oncol Hematol 2022; 176:103728. [PMID: 35662585 DOI: 10.1016/j.critrevonc.2022.103728] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 01/11/2023] Open
Abstract
Examining and addressing unmet care needs is integral to improving the provision and quality of cancer services. This review explored the prevalence of unmet supportive care needs, and factors associated with unmet need, in adults with advanced cancers (solid and hematological malignancies) and their caregivers. Electronic databases (PubMed, CINAHL, EMBASE) were searched, producing 85 papers representing 81 included studies. People with advanced cancer reported the highest unmet needs in financial, health system and information, psychological, and physical and daily living domains, whereas caregivers reported the highest unmet needs in psychological, and patient care and support domains. Distress, depression, and anxiety were associated with higher unmet needs across all unmet need domains for people with advanced cancer and their caregivers. Substantial heterogeneity in study populations and methods was observed. Findings from this review can inform targeted strategies and interventions to address these unmet needs in people with advanced cancer.
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Affiliation(s)
- Nicolas H Hart
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, SA, Australia; Exercise Medicine Research Institute, School of Medical and Health Sciences, Edith Cowan University, WA, Australia; Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, QLD, Australia; Institute for Health Research, University of Notre Dame Australia, WA, Australia.
| | - Fiona Crawford-Williams
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, SA, Australia; Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, QLD, Australia
| | - Megan Crichton
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, QLD, Australia; Nutrition and Dietetics Research Group, Bond University, QLD, Australia
| | - Jasmine Yee
- Centre for Medical Psychology and Evidence-Based Decision-Making, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Thomas J Smith
- Division of General Internal Medicine, John Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bogda Koczwara
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, SA, Australia; Flinders Cancer and Innovation Centre, Flinders Medical Centre, SA, Australia
| | - Margaret I Fitch
- School of Graduate Studies, Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Gregory B Crawford
- Discipline of Medicine, University of Adelaide, SA, Australia; Northern Adelaide Local Health Network, SA, Australia
| | - Sandip Mukhopadhyay
- Burdwan Medical College, West Bengal, Kolkata, India; Indian Council of Medical Research, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | | | - Chan Cheah
- Internal Medicine, UWA Medical School, University of Western Australia, WA, Australia; Department of Haematology, Sir Charles Gairdner Hospital, WA, Australia; Department of Haematology, Hollywood Private Hospital, WA, Australia
| | | | - Olivia Cook
- McGrath Foundation, NSW, Australia; School of Nursing and Midwifery, Monash University, VIC, Australia
| | - Meera R Agar
- IMPACCT Centre, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, SA, Australia; Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, QLD, Australia
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Krause R, Barnard A, Burger H, De Vos A, Evans K, Farrant L, Fouche N, Kalula S, Morgan J, Mohamed Z, Panieri E, Ras T, Raubenheimer P, Verburg E, Boyd K, Gwyther L. A Delphi study to guide the development of a clinical indicator tool for palliative care in South Africa. Afr J Prim Health Care Fam Med 2022; 14:e1-e7. [PMID: 35695438 PMCID: PMC9210161 DOI: 10.4102/phcfm.v14i1.3351] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/14/2022] [Accepted: 03/31/2022] [Indexed: 11/09/2022] Open
Abstract
Background The South African National Policy Framework and Strategy on Palliative Care (NPFSPC) recommends that when integrating palliative care (PC) into the health system, a PC indicators tool should be used to guide clinicians to recognise a patient who should receive PC. The policy document recommends ‘a simple screening tool developed for use in South Africa that would assist healthcare professionals (HCPs) to recognise patients who may have unmet palliative care needs’. Aim This research study sought to develop South African consensus on indicators for PC to assist clinicians to recognise a patient in need of PC. Setting The South African healthcare setting. Methods A Delphi study was considered suitable as a methodology to develop consensus. The methodology was based on the Conducting and REporting of DElphi studies (CREDES) guidance on Delphi studies to ensure rigour and transparency in conducting and reporting. Six different Delphi rounds were used to develop consensus. Each round allowed participants to anonymously rate statements with predefined rating scales. Results Cognisant of the disparities in healthcare provision and access to equitable healthcare in South Africa, the expert advisory group recommended, especially for South Africa, that ‘this tool is for deteriorating patients with an advanced life-limiting illness where all available and appropriate management for underlying illnesses and reversible complications has been offered’. The expert advisory group felt that disease-specific indicators should be described before the general indicators in the South African indicators tool, so all users of the tool orientate themselves to the disease categories first. This study included three new domains to address the South African context: trauma, infectious diseases and haematological diseases. General indicators for PC aligned with the original Supportive and Palliative Care Indicators Tool (SPICT) tool. Conclusion The Supportive and Palliative Care Indicators Tool for South Africa (SPICTTM-SA) is a simple screening tool for South Africa that may assist HCPs to recognise patients who may have unmet PC needs.
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Affiliation(s)
- Rene Krause
- Department of Family Medicine and Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town.
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Intensity of care in cancer patients in the last year of life: a retrospective data linkage study. Br J Cancer 2022; 127:712-719. [PMID: 35545681 PMCID: PMC9092325 DOI: 10.1038/s41416-022-01828-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Delivering high-quality palliative and end-of-life care for cancer patients poses major challenges for health services. We examine the intensity of cancer care in England in the last year of life. Methods We included cancer decedents aged 65+ who died between January 1, 2010 and December 31, 2017. We analysed healthcare utilisation and costs in the last 12 months of life including hospital-based activities and primary care. Results Healthcare utilisation and costs increased sharply in the last month of life. Hospital costs were the largest cost elements and decreased with age (0.78, 95% CI: 0.73–0.72, p < 0.005 for age group 90+ compared to age 65–69 and increased substantially with comorbidity burden (2.2, 95% CI: 2.09–2.26, p < 0.005 for those with 7+ comorbidities compared to those with 1–3 comorbidities). The costs were highest for haematological cancers (1.45, 95% CI: 1.38–1.52, p < 0.005) and those living in the London region (1.10, 95% CI: 1.02–1.19, p < 0.005). Conclusions Healthcare in the last year of life for advanced cancer patients is costly and offers unclear value to patients and the healthcare system. Further research is needed to understand distinct cancer populations’ pathways and experiences before recommendations can be made about the most appropriate models of care.
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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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Abstract
Purpose of this Review The purpose of this review is to describe the evolution of palliative care in paediatric oncology, the needs of children and their families in a paediatric oncology setting, palliative care referral practices in paediatric oncology, outcomes of palliative care referral in paediatric oncology and models of palliative care in paediatric oncology. Recent Findings Cancer constitutes 5.2% of the palliative care needs in children. Approximately, 90% of children with cancer lives in low and middle-income countries, constituting 84% of the global burden of childhood cancers. Children in low and middle-income countries have low cure rates and high death rates making palliative care relevant in a paediatric oncology setting. Children with cancer experience pain and physical symptoms, low mood, anxiety, and fear. They feel less resilient, experience low self-worth, and have challenges coping with the illness. The families lead very stressful lives, navigating the hospital environment, and dealing with uncertainties of the future. Palliative care referral in children with cancer improves physical symptoms, emotional support, and quality of life. It enables communication between families and health care providers. It improves end-of-life care support to children and their families and facilitates less invasive diagnostic and therapeutic interventions at the end of life. Worldwide children with cancer are infrequently referred to palliative care and referred late in the illness trajectory. Most of the children referred to palliative care receive some form of cancer-directed therapy in their last days. Children in low and low-middle income countries are less likely to access palliative care due to a lack of awareness amongst paediatric oncologists about palliative care and the reduced number of services providing palliative care. A three-tier model is proposed to provide palliative care in paediatric oncology, where most children with palliative care needs are managed by paediatric oncologists and a smaller number with complex physical and psychosocial needs are managed by paediatric palliative care specialists. There are several palliative care models in paediatric oncology practised globally. However, no one model was considered better or superior, and the choice of model depended on the need, preferences identified, and available resources. Summary Children with cancer are sparingly referred to palliative care and referred late and oncologists and haematologists gatekeep the referral process. Knowledge on palliative care referral in paediatric oncology settings might enhance collaboration between paediatric oncology and paediatric palliative care.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Sean Hughes
- Division of Health Research, Health Innovation One, Lancaster University, Sir John Fisher Drive, Lancaster, LA1 4AT UK
| | - Nancy Preston
- Division of Health Research, Health Innovation One, Lancaster University, Sir John Fisher Drive, Lancaster, LA1 4AT UK
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Pasquarella AV, Islam S, Ramdhanny A, Gendy M, Pinto P, Braunstein MJ. Outcomes of Patients With Hematologic Malignancies Who Received Inpatient Palliative Care Consultation. JCO Oncol Pract 2022; 18:e688-e696. [PMID: 34986010 DOI: 10.1200/op.21.00502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Palliative care (PC) plays an established role in improving outcomes in patients with solid tumors, yet these services are underutilized in hematologic malignancies (HMs). We reviewed records of hospitalized patients with active HM to determine associations between PC consultation and length of stay, intensive care unit stay, 30-day readmission, and 6-month mortality compared with those who were not seen by PC. METHODS We reviewed all oncology admissions at our institution between 2013 and 2019 and included patients with HM actively on treatment, stratified by those seen by PC to controls not seen by PC. Groups were compared using Wilcoxon rank-sum, chi-square, and Fisher's exact tests on the basis of the type and distribution of data. Multiple logistic regression models with stepwise variable selection methods were used to find predictors of outcomes. RESULTS Three thousand six hundred fifty-four admissions were reviewed, among which 370 unique patients with HM were included. Among these, 102 (28%) patients saw PC, whereas the remaining 268 were controls with similar comorbidities. When compared with controls, PC consultation was associated with a statistically significant reduction in 30-day readmissions (16% v 27%; P = .024), increased length of stay (11.5 v 6 days; P < .001), increased intensive care unit admission (28% v 9%; P < .001), and increased 6-month mortality (67% v 15%; P < .001). These data were confirmed in multivariable models. CONCLUSION In this retrospective study, more than two thirds of patients with HM did not receive PC consultation despite having similar comorbidities, suggesting that inpatient PC consultation is underutilized in patients with HM, despite the potential for decreased readmission rates.
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Affiliation(s)
- Anthony V Pasquarella
- Department of Medicine, Division of Oncology-Hematology, NYU Long Island School of Medicine, NYU Perlmutter Cancer Center, Mineola, NY
| | - Shahidul Islam
- Department of Biostatistics, NYU Long Island School of Medicine, Mineola, NY
| | - Angela Ramdhanny
- Department of Medicine, Division of Oncology-Hematology, NYU Long Island School of Medicine, NYU Perlmutter Cancer Center, Mineola, NY
| | - Mina Gendy
- Department of Medicine, Division of Oncology-Hematology, NYU Long Island School of Medicine, NYU Perlmutter Cancer Center, Mineola, NY
| | - Priya Pinto
- Department of Medicine, Division of Palliative Care, NYU Long Island School of Medicine, Mineola, NY
| | - Marc J Braunstein
- Department of Medicine, Division of Oncology-Hematology, NYU Long Island School of Medicine, NYU Perlmutter Cancer Center, Mineola, NY
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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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Santivasi WL, Childs DS, Wu KL, Partain DK, Litzow MR, LeBlanc TW, Strand JJ. Perceptions of Hematology Among Palliative Care Physicians: Results of a Nationwide Survey. J Pain Symptom Manage 2021; 62:949-959. [PMID: 33933620 DOI: 10.1016/j.jpainsymman.2021.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Palliative care integration for patients with hematologic diseases has lagged behind solid-organ malignancies. Previous work has characterized hematologist perspectives, but less is known about palliative care physician views of this phenomenon. OBJECTIVES To examine palliative care physician attitudes and beliefs regarding hematologic diseases, patient care, and collaboration. METHODS A 44-item survey containing Likert and free-response items was mailed to 1000 AAHPM physician members. Sections explored respondent comfort with specific diagnoses, palliative care integration, relationships with hematologists, and hematology-specific patient care. Logistic regression models with generalized estimating equations were used to compare parallel Likert responses. Free responses were analyzed using thematic analysis. RESULTS The response rate was 55.5%. Respondents reported comfort managing symptoms in leukemia (84.0%), lymphoma (92.1%), multiple myeloma (92.9%), and following hematopoietic stem cell transplant (51.6%). Fewer expressed comfort with understanding disease trajectory (64.9%, 75.7%, 78.5%, and 35.4%) and discussing prognosis (71.0%, 82.6%, 81.6%, and 40.6%). 97.6% of respondents disagreed that palliative care and hematology are incompatible. 50.6% felt that palliative care physicians' limited hematology-specific knowledge hinders collaboration. 89.4% felt that relapse should trigger referral. 80.0% felt that hospice referrals occurred late. In exploring perceptions of hematology-palliative care relationships, three themes were identified: misperceptions of palliative care, desire for integration, and lacking a shared model of understanding. CONCLUSION These data inform efforts to integrate palliative care into hematologic care at large, echoing previous studies of hematologist perspectives. Palliative care physicians express enthusiasm for caring for these patients, desire for improved understanding of palliative care, and ongoing opportunities to improve hematology-specific knowledge and skills.
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Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States.
| | - Daniel S Childs
- Departments of Medicine and Oncology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kelly L Wu
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Scottsdale, Arizona, United States
| | - Daniel K Partain
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Jacob J Strand
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States
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Gemmell R, Halley A, Stevens AM, Allam A, Perkins M, Ethell M, Sriskandarajah P, Droney J. Palliative care for patients around the time of haematopoietic stem cell transplant: a qualitative study of patients' perceptions and experiences of unmet need and attitudes towards palliative care involvement. Support Care Cancer 2021; 30:2253-2261. [PMID: 34716484 DOI: 10.1007/s00520-021-06556-4] [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: 04/15/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Haemato-oncology patients are likely to be referred later to palliative care than patients with solid tumours, despite experiencing similar symptom burden. Patients prior to stem cell transplant may benefit from symptom control, advance care planning and shared decision-making, and previous studies have demonstrated feasibility and benefit of such a service. However, the views of patients are not yet established, and are vital to ensure acceptability of the service. AIMS To identify areas where a palliative care team may help to support patients being considered for a stem cell transplant, and to explore the attitudes and perceptions of patients towards palliative care at this time. DESIGN A qualitative study including interviews (N = 12) and a focus group (N = 4) for patients pre- and post-transplant, using a semi-structured format via telephone, online video-conferencing and face-to-face discussions. Recordings were transcribed and analysed using thematic analysis. SETTING A tertiary cancer centre in the UK. FINDINGS Themes identified were the following: Identified needs, Information and decision-making, Importance of relationships, Changing perceptions of what palliative care means, and The future. Patients associate palliative care with terminal care due to indirect experiences. Patients were open to palliative care once its purpose was explained and described emotional and physical needs relevant to early palliative care. CONCLUSIONS The involvement of early palliative care alongside haematology treatment prior to stem cell transplant may improve quality of life for patients and facilitate shared decision-making at a crucial stage of treatment. Early palliative care should be offered alongside haematology care around the time of stem cell transplant, with information provided to patients regarding its role.
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Affiliation(s)
- Rebecca Gemmell
- Palliative Care Department, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK.
| | - Angela Halley
- Palliative Care Department, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | - Anna-Marie Stevens
- Palliative Care Department, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | - Alison Allam
- Public and Patient Representative, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | - Margaret Perkins
- Public and Patient Representative, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | - Mark Ethell
- Haematology Department, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | - Priya Sriskandarajah
- Haematology Department, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
| | - Joanne Droney
- Palliative Care Department, Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ, UK
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Salazar MM, DeCook LJ, Butterfield RJ, Zhang N, Sen A, Wu KL, Vanness DJ, Khera N. End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. J Palliat Med 2021; 25:97-105. [PMID: 34705545 DOI: 10.1089/jpm.2021.0093] [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: 11/12/2022] Open
Abstract
Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.
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Affiliation(s)
- Marisa M Salazar
- Mayo Clinic Alix School of Medicine, Mayo Clinic College of Science and Medicine, Scottsdale, Arizona, USA
| | - Lori J DeCook
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Nan Zhang
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelly L Wu
- Division of General Internal Medicine, Center for Palliative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - David J Vanness
- Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Mun S, Wang R, Ma X, Ananth P. Sociodemographic and hospital-based predictors of intense end-of-life care among children, adolescents, and young adults with hematologic malignancies. Cancer 2021; 127:3817-3824. [PMID: 34185881 PMCID: PMC8478813 DOI: 10.1002/cncr.33764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/07/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children, adolescents, and young adults with hematologic malignancies tend to receive high-intensity end-of-life care (HI-EOLC), but sociodemographic and hospital-based predictors of HI-EOLC remain unclear. METHODS The authors conducted a population-based, retrospective cohort study with the Premier Healthcare Database. They identified individuals with hematologic malignancies who were 0 to 39 years old at death and died between 2010 and 2017. HI-EOLC was defined as experiencing 2 or more of the following: cardiopulmonary resuscitation, intravenous chemotherapy, hemodialysis, mechanical ventilation, tracheostomy placement, or an emergency department visit within the last 30 days of life and death in the intensive care unit. Multivariable logistic regression models were constructed to identify patient sociodemographic and hospital characteristics associated with HI-EOLC. RESULTS Among 1454 decedents, more than half (55%) experienced HI-EOLC. In multivariable models, patients treated in medium (adjusted odds ratio [aOR], 1.63; 95% confidence interval [CI], 1.07-2.50) or large hospitals (aOR, 2.21; 95% CI, 1.45-3.39), insured by Medicaid (aOR, 1.40 ; 95% CI, 1.09-2.06), or receiving cancer-directed treatment in the Northeast (aOR, 1.50; 95% CI, 1.05-2.15) were more likely to receive HI-EOLC. CONCLUSIONS A majority of children, adolescents, and young adults with hematologic malignancies experienced HI-EOLC, and the likelihood of HI-EOLC was influenced by the hospital size, type of insurance, and geographic region. Further research is needed to determine how to mitigate these risks.
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Affiliation(s)
- Sophia Mun
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Prasanna Ananth
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Pediatrics, Yale School of Medicine, New
Haven, CT
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Elliott E, Watson T, Singh D, Wong C, Lo SS. Outcomes of Specialty Palliative Care Interventions for Patients With Hematologic Malignancies: A Systematic Review. J Pain Symptom Manage 2021; 62:863-875. [PMID: 33774128 DOI: 10.1016/j.jpainsymman.2021.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/22/2022]
Abstract
CONTEXT The outcomes of specialty palliative care (PC) interventions for patients with hematologic malignancies (HMs) is under-investigated. OBJECTIVES We performed a systematic review to evaluate the effect of PC interventions on patient- and caregiver- reported outcomes and healthcare utilization among adults with HMs (leukemia, myeloma, and lymphoma). METHODS From database inception through September 10, 2020, we systematically searched PubMed, CINAHL, Embase, Scopus, Web of Science, and Cochrane Reviews using terms representing HMs and PC. Eligible studies investigated adults aged 18 years and older, were published in the English language, and contained original, quantitative, or qualitative data related to patient- and/or caregiver-centered outcomes and healthcare utilization. RESULTS We screened 5345 studies;16 met inclusion criteria and found that specialty PC led to improved symptom management, decreased likelihood of inpatient death, decreased healthcare utilization, decreased cost of healthcare, and improved caregiver-reported outcomes. Patients with HM have a high need for PC which, though increasing over time, is often provided late in the clinical disease course. CONCLUSIONS Specialty PC interventions improve healthcare outcomes for patients with HMs and should be implemented early and often. There remains a need for additional studies investigating PC use exclusively in patients with HMs.
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Affiliation(s)
- Elizabeth Elliott
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Stritch School of Medicine, Maywood, Illinois, USA.
| | - Tracie Watson
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Daulath Singh
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Connie Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Shelly S Lo
- Department of Medicine, Division of Hematology and Oncology, Cardinal Bernardin Cancer Center, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
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Perspectives on Advance Care Planning for Patients with Hematologic Malignancy: An International Clinician Questionnaire. Ann Am Thorac Soc 2021; 18:1533-1539. [PMID: 33400904 DOI: 10.1513/annalsats.202006-678oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rationale: Critical illness is common in patients with hematologic malignancy (HM). Advance care planning (ACP) can allow these patients to express their care preferences before life-threatening illnesses. Objectives: To evaluate physicians' perspectives surrounding ACP in patients with HM. Methods: We administered a survey to intensivists and hematologic oncologists who care for patients with HM across Canada and the United Kingdom. Potential respondents were identified from institutions that have a hematologic-oncology program. The survey was disseminated electronically. Results: A total of 111 physicians completed the survey, with a response rate of 19% (39% across those who opened the e-mail); 52% of respondents were intensivists, and 48% of respondents were hematologic oncologists. Of the responses, 15.5% of physicians reported that ACP happens routinely at their institution, whereas 8.3% of physicians stated that code status is routinely discussed. ACP discussions were most commonly reported at the onset of critical illness (84.3% of respondents), during disease recurrence (52.9% of respondents), or during the transition to a strictly palliative approach (54.9% of respondents). Commonly cited barriers to ACP centered on physicians' concern about the reaction of the patient or family. Conclusions: This study emphasizes the need for earlier and more frequent ACP discussions in this high-risk population with a variety of barriers identified.
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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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End-of-life care quality outcomes among Medicare beneficiaries with hematologic malignancies. Blood Adv 2021; 4:3606-3614. [PMID: 32766855 DOI: 10.1182/bloodadvances.2020001767] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023] Open
Abstract
Patients with hematologic malignancies are thought to receive more aggressive end-of-life (EOL) care and have suboptimal hospice use compared with patients with solid tumors, but descriptions of EOL outcomes from comprehensive cohorts have been lacking. We used the population-based Surveillance, Epidemiology, and End Results-Medicare dataset to describe hospice use and indicators of aggressive EOL care among Medicare beneficiaries who died of hematologic malignancies in 2008-2015. Overall, 56.5% of decedents used hospice services for median 9 days (interquartile range, 3-27), 33.0% died in an acute hospital setting, 36.8% had an intensive care unit (ICU) admission in the last 30 days of life, and 13.3% received chemotherapy within the last 14 days of life. Hospice use was associated with 96% lower probability of inpatient death (adjusted risk ratio [aRR], 0.038; 95% confidence interval [CI], 0.035-0.042), 44% lower probability of an ICU stay in the last 30 days of life (aRR, 0.56; 95% CI, 0.54-0.57), and 62% decrease in chemotherapy use in the last 14 days of life (aRR, 0.38; 95% CI, 0.35-0.41). Hospice enrollees spent on average 41% fewer days as inpatient during the last month of life (adjusted means ratio, 0.59; 95% CI, 0.57-0.60) and had 38% lower mean Medicare spending in the last month of life (adjusted means ratio, 0.62; 95% CI, 0.61-0.64). These associations were consistent across histologic subgroups. In conclusion, EOL care quality outcomes and hospice enrollment were suboptimal among older decedents with hematologic cancers, but hospice use was associated with a consistent decrease in aggressive care at EOL.
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What is known about palliative care in adult patients with allogeneic stem cell transplantation (allo-SCT)? Ann Hematol 2021; 100:1377-1389. [PMID: 33954817 PMCID: PMC8116288 DOI: 10.1007/s00277-021-04538-4] [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] [Received: 12/23/2020] [Accepted: 04/19/2021] [Indexed: 11/02/2022]
Abstract
Patients undergoing allogeneic stem cell transplantation (allo-SCT) are given a real chance of cure, but at the same time are confronted with a considerable risk of mortality and of severe long-term impediments. This narrative, non-systematic literature review aims to describe the supportive and palliative care needs of allo-SCT recipients, including long-term survivors or those relapsing or dying after transplantation. It also evaluates the feasibility and effectivity of integrating palliative care early in transplant procedures. In this appraisal of available literature, the main findings relate to symptoms like fatigue and psychological distress, which appear to be very common in the whole allo-SCT trajectory and might even persist many years post-transplantation. Chronic GvHD has a major negative impact on quality of life. Overall, there is a paucity of research on further issues in the context of allo-SCT, like the distress related to the frequently unpredictable post-transplant trajectory and prognosis, as well as the end-of-life phase. First randomized controlled results support the effectiveness of early integration of specialized palliative care expertise into transplant algorithms. Barriers to this implementation are discussed.
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Dhawan N, LeBlanc TW. Lean Into the Uncomfortable: Using Trauma-Informed Care to Engage in Shared Decision-Making With Racial Minorities With Hematologic Malignancies. Am J Hosp Palliat Care 2021; 39:4-8. [PMID: 33910380 DOI: 10.1177/10499091211008431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Discussions involving racial health disparities must include pathways for engaging in shared decision-making with racial/ethnic minorities. Research demonstrates glaring racial and ethnic disparities when it comes to hematologic malignancies from the time of diagnosis to treatment and even at the end of life. Unfortunately, decision-making in these circumstances may be streamlined, given the urgency of the disease, prognostic uncertainty, and varying treatment options. Being diagnosed with cancer is undoubtedly a traumatic experience and a patient's race and/or ethnicity add an important dimension to their experience. The tenets of trauma-informed care (TIC) are anchored in recognizing that trauma can manifest in several ways and acknowledging the impact of past trauma on a patient's present and future behaviors. We argue that using a TIC approach may help hematologists create a space for decision-making while minimizing the risk of re-traumatization and perpetuating racial disparities. Using the foundation of TIC, an interprofessional team can begin addressing manifestations of trauma and hopefully mitigate racial and ethnic disparities.
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Affiliation(s)
- Natasha Dhawan
- 22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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40
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Kuczmarski TM, Odejide OO. Goal of a "Good Death" in End-of-Life Care for Patients with Hematologic Malignancies-Are We Close? Curr Hematol Malig Rep 2021; 16:117-125. [PMID: 33864180 DOI: 10.1007/s11899-021-00629-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The medical field has a critical role not only in prolonging life but also in helping patients achieve a good death. Early studies assessing end-of-life quality indicators to capture if a good death occurred demonstrated low rates of hospice use and high rates of intensive healthcare utilization near death among patients with hematologic malignancies, raising concerns about the quality of death. In this review, we examine trends in end-of-life care for patients with hematologic malignancies to determine if we are close to the goal of a good death. RECENT FINDINGS Several cohort studies show that patients with blood cancers are often inadequately prepared for the dying process due to late goals of care discussions and they experience low rates of palliative and hospice care. More recent analyses of population-based data demonstrate some improvements over time, with significantly more patients receiving palliative care, enrolling in hospice, and having the opportunity to die at home compared to a decade ago. These encouraging trends are paradoxically accompanied by concomitant increases in late hospice enrollment and intensive healthcare utilization near death. Although we are closer to the goal of a good death for patients with hematologic malignancies, there is ample room for growth. To close the gap between the current state of care and a good death, we need research that engages patients, caregivers, hematologic oncologists, and policy-makers to develop innovative interventions that improve timeliness of goals of care discussions, expand palliative care integration, and increase hospice use.
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Affiliation(s)
- Thomas M Kuczmarski
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Oreofe O Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Sheridan R, Roman E, Smith AG, Turner A, Garry AC, Patmore R, Howard MR, Howell DA. Preferred and actual place of death in haematological malignancies: a report from the UK haematological malignancy research network. BMJ Support Palliat Care 2021; 11:7-16. [PMID: 32393531 PMCID: PMC7907576 DOI: 10.1136/bmjspcare-2019-002097] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/18/2020] [Accepted: 04/04/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Hospital death is comparatively common in people with haematological cancers, but little is known about patient preferences. This study investigated actual and preferred place of death, concurrence between these and characteristics of preferred place discussions. METHODS Set within a population-based haematological malignancy patient cohort, adults (≥18 years) diagnosed 2004-2012 who died 2011-2012 were included (n=963). Data were obtained via routine linkages (date, place and cause of death) and abstraction of hospital records (diagnosis, demographics, preferred place discussions). Logistic regression investigated associations between patient and clinical factors and place of death, and factors associated with the likelihood of having a preferred place discussion. RESULTS Of 892 patients (92.6%) alive 2 weeks after diagnosis, 58.0% subsequently died in hospital (home, 20.0%; care home, 11.9%; hospice, 10.2%). A preferred place discussion was documented for 453 patients (50.8%). Discussions were more likely in women (p=0.003), those referred to specialist palliative care (p<0.001), and where cause of death was haematological cancer (p<0.001); and less likely in those living in deprived areas (p=0.005). Patients with a discussion were significantly (p<0.05) less likely to die in hospital. Last recorded preferences were: home (40.6%), hospice (18.1%), hospital (17.7%) and care home (14.1%); two-thirds died in their final preferred place. Multiple discussions occurred for 58.3% of the 453, with preferences varying by proximity to death and participants in the discussion. CONCLUSION Challenges remain in ensuring that patients are supported to have meaningful end-of-life discussions, with healthcare services that are able to respond to changing decisions over time.
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Affiliation(s)
- Rebecca Sheridan
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Alex G Smith
- Epidemiology & Cancer Statistics Group, Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Andrew Turner
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, UK
| | - Anne C Garry
- Department of Palliative Care, York Hospital, York, YO31 8HE, UK
| | - Russell Patmore
- Queens 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, Department of Health Sciences, University of York, York, North Yorkshire, UK
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Salins N, Ghoshal A, Hughes S, Preston N. How views of oncologists and haematologists impacts palliative care referral: a systematic review. BMC Palliat Care 2020; 19:175. [PMID: 33228651 PMCID: PMC7686696 DOI: 10.1186/s12904-020-00671-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/14/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Worldwide, many patients with cancer, are infrequently referred to palliative care or are referred late. Oncologists and haematologists may act as gatekeepers, and their views may facilitate or hinder referrals to palliative care. This review aimed to identify, explore and synthesise their views on referrals systematically. METHODS Databases of MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science and Cochrane were searched for articles from 01/01/1990 to 31/12/2019. All studies were scored for their methodological rigour using Hawker's tool. Findings were synthesised using Popay's narrative synthesis method and interpreted using a critical realist lens and social exchange theory. RESULTS Out of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis. 1. Presuppositions of oncologists and haematologists about palliative care referral: Role conflict, abandonment, rupture of therapeutic alliance and loss of hope were some of the presuppositions that hindered palliative care referral. Negative emotions and perception of self-efficacy to manage palliative care need also hindered referral. 2. Power relationships and trust issues: Oncologists and haematologists preferred to gatekeep the referral process and wished to control and coordinate the care process. They had diminished trust in the competency of palliative care providers. 3. Making a palliative care referral: A daunting task: The stigma associated with palliative care, navigating illness and treatment associated factors, addressing patient and family attitudes, and overcoming organisational challenges made referral a daunting task. Lack of referral criteria and limited palliative care resources made the referral process challenging. 4. Cost-benefit of palliative care referral: Pain and symptom management and psychosocial support were the perceived benefits, whereas inconsistencies in communication and curtailment of care were some of the costs associated with palliative care referral. 5. Strategies to facilitate palliative care referral: Developing an integrated model of care, renaming and augmenting palliative care resources were some of the strategies that could facilitate a referral. CONCLUSION Presuppositions, power relationships, trust issues and the challenges associated with the task of referrals hindered palliative care referral. Oncologists and haematologists appraised the cost-benefit of making a palliative care referral. They felt that an integrated model of care, changing the name of palliative care and augmenting palliative care resources might facilitate a referral.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Centre, MB-G-75, DR E Borges Road, Parel, Mumbai, 400012, India
| | - Sean Hughes
- Division of Health Research, Faculty of Health and Medicine, Furness College, Lancaster University, C051, C - Floor, Bailrigg, LA1 4YW, UK
| | - Nancy Preston
- Division of Health Research, Faculty of Health and Medicine, Furness College, Lancaster University, C051, C - Floor, Bailrigg, LA1 4YW, UK.
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Palliative care in onco-hematology: a perspective. Support Care Cancer 2020; 29:2251-2253. [PMID: 33219406 DOI: 10.1007/s00520-020-05895-y] [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: 06/11/2020] [Accepted: 11/16/2020] [Indexed: 10/23/2022]
Abstract
Palliative care (PC) is focused on individualized symptomatic control, psychological help, and support in the context of severe disease. Oncologic patients are still the most referred to PC and hematologic patients are only 7%. This is a commentary about PC applied to hematologic patients. There is evidence supporting that these patients behave as a special group in PC when compared with other tumors: there is a smaller number of referrals, with more advanced disease status, more symptomatology expressed, and less time between the last treatment date and the referral date or death. This article also expresses the experience of an oncologic palliative care unit. More health education programs in PC are needed for specialized professionals in hematology, as well as a change of nowadays health politics, in order to increase the participation of this specialized care in hematology.
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Cooper A, Dains JE. Advanced Care Planning and End-of-life Outcomes in Hematopoietic Stem Cell Transplant Patients. Am J Hosp Palliat Care 2020; 38:995-1003. [PMID: 33161732 DOI: 10.1177/1049909120971566] [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: 11/15/2022] Open
Abstract
AIM/PURPOSE This integrative review addresses whether the presence and timing of advanced care planning (ACP) with or without a palliative care (PC) consultation affect place of death and use of high-intensity medical care at end-of-life (EOL) in adolescent and young adult and adult cancer patients receiving hematopoietic stem cell transplant (HSCT) therapy. METHODS AND RESULTS A literature search was completed in the Scopus and PubMed databases. The search was not restricted by date but was restricted to English language. A total of 1,616 articles were found, and after exclusion of duplicates and irrelevance, 79 articles were available to review. After reviewing inclusion and exclusion criteria, 9 articles related to ACP with HSCT were found, and 4 were eliminated after further review, resulting in 5 viable articles for review related to EOL outcomes. EOL outcomes reviewed were place of death and high-intensity medical care. Factors noted to influence these measures included the presence or absence of ACP, the timing of ACP, and PC consultation. Overall survival also emerged as an EOL outcome affected by ACP. CONCLUSION Although there have been many barriers identified to ACP discussions in the HSCT population, the findings from the integrative literature review support the use of early ACP with patients who have hematologic malignancies undergoing HSCT to address patient EOL goals and reduce healthcare utilization at the EOL. The data also suggest that identification of patients who would most benefit from early engagement in ACP may positively impact outcomes.
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Affiliation(s)
- Alexandra Cooper
- 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joyce E Dains
- 4002The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lewis EA. Optimiser les soins palliatifs précoces aux patients atteints d’un cancer hématologique recevant une greffe de cellules souches : rôle de l’infirmière praticienne. Can Oncol Nurs J 2020; 30:246-252. [PMID: 33165342 DOI: 10.5737/23688076304246252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
La greffe de cellules souches hématopoïétiques (GCSH) est une approche thérapeutique intensive des hémopathies malignes qui s’accompagne d’un important risque de morbidité et de mortalité. Malgré la lueur d’espoir qu’elle apporte aux patients, les traitements sont longs et pénibles, tant du point de vue physique que psychosocial. Habituellement, la greffe de cellules souches hématopoïétiques a une visée curative qui laisse peu de place à un partenariat éventuel avec les services de soins palliatifs et, lorsque ces derniers sont proposés, il est souvent trop tard pour en tirer un bénéfice notable. Il faudrait donc systématiser le recours aux soins palliatifs pour les patients atteints d’hémopathie maligne qui reçoivent une GCSH; cependant, il demeure difficile de trouver la meilleure voie pour établir un tel partenariat. Les infirmières praticiennes, qui sont de plus en plus nombreuses, possèdent les connaissances et les compétences requises pour combler les lacunes dans la prestation de soins palliatifs aux patients recevant une GCSH. L’algorithme de soins palliatifs précoces dispensés par les infirmières praticiennes aux patients recevant une GCSH (dit NEST en anglais, pour « Nurse-Practitioner-Delivered Early Palliative Care for Stem Cell Transplant ») vise justement à faire le pont entre les services palliatifs et les équipes d’hématologie et de greffe afin d’offrir aux patients les meilleurs soins possible.
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Affiliation(s)
- Ellen A Lewis
- infirmière praticienne, hématologie, Tom Baker Cancer Centre, Foothills Medical Centre, AB,
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Tanzi S, Venturelli F, Luminari S, Merlo FD, Braglia L, Bassi C, Costantini M. Early palliative care in haematological patients: a systematic literature review. BMJ Support Palliat Care 2020; 10:395-403. [DOI: 10.1136/bmjspcare-2020-002386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/24/2020] [Accepted: 09/04/2020] [Indexed: 12/29/2022]
Abstract
BackgroundEarly palliative care together with standard haematological care for advanced patients is needed worldwide. Little is known about its effect. The aim of the review is to synthesise the evidence on the impact of early palliative care on haematologic cancer patients’ quality of life and resource use.Patients and methodsA systematic review was conducted. The search terms were early palliative care or simultaneous or integrated or concurrent care and haematological or oncohaematological patients. The following databases were searched: PubMed, Embase, Cochrane, CINHAL and Scopus. Additional studies were identified through cross-checking the reference articles. Studies were in the English language, with no restriction for years. Two researchers independently reviewed the titles and abstracts, and one author assessed full articles for eligibility.ResultsA total of 296 studies titles were reviewed. Eight articles were included in the synthesis of the results, two controlled studies provided data on the comparative efficacy of PC interventions, and six one-arm studies were included. Since data pooling and meta-analysis were not possible, only a narrative synthesis of the study results was performed. The quality of the two included comparative studies was low overall. The quality of the six non-comparative studies was high overall, without the possibility of linking the observed results to the implemented interventions.ConclusionsStudies on early palliative care and patients with haematological cancer are scarce and have not been prospectively designed. More research on the specific population target, type and timing of palliative care intervention and standardisation of collected outcomes is required.PROSPERO registration numberCRD42020141322.
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Prod'homme C. [Palliative care medical consultation in a hematology department. Feedback and critical reflection on a year of practice]. Bull Cancer 2020; 107:1118-1128. [PMID: 33059871 DOI: 10.1016/j.bulcan.2020.08.015] [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: 06/11/2020] [Revised: 07/29/2020] [Accepted: 08/29/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Patients with hematological malignancies have less access to palliative care than other cancer patients, and benefit from it later in the course of their disease, though symptom burden is just as heavy. METHODS We created a specialized outpatient palliative care consultation in the hematology department to improve the quality of patient management and enhance cooperation with hematologists. RESULTS We found that though patient characteristics and survival were extremely variable, they all had in common a need for symptom management and care coordination. As a result of the consultation, hematology teams called upon a specialized palliative care multidisciplinary team more often to meet patients hospitalized within their departments, and more patients with hematological malignancies hemopathies were hospitalized in palliative care units. DISCUSSION We describe the benefits that can be anticipated when collaboration increases between hematology and palliative care, including early on in the course of disease. It is now up to policy-makers to establish priorities regarding the allocation of health resources, in particular regarding end-of-life. This requires identifying patient needs, optimizing patient access to specialized palliative care, and improving the pertinence of palliative care interventions as they cannot be generalized.
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Affiliation(s)
- Chloé Prod'homme
- CHU de Lille, clinique de médecine palliative, université de Lille, CNRS, 2, avenue Oscar-Lambret, 59000 Lille, France; Université Catholique de Lille, centre d'éthique médical, faculté de médecine et de maïeutique de Lille, ETHICS (Experiment, Transhumanism, Human Interactions, Care and Society) - EA 7446, 46, rue du Port, 59000 Lille, France.
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Ebelhar J, Allen K, DeGroote N, Wasilewski-Masker K, Brock KE. Defining palliative opportunities in pediatric patients with bone and soft tissue sarcomas. Pediatr Blood Cancer 2020; 67:e28363. [PMID: 32706495 DOI: 10.1002/pbc.28363] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pediatric patients with sarcomas experience significant morbidity and compromised quality of life throughout their course. These times could be viewed as opportunities for increased subspecialty palliative care (PC). Systematically defining opportunities for additional PC support has not occurred in pediatric oncology. The frequency, timing, and associated factors for palliative opportunities in pediatric patients with sarcomas are unknown. METHODS A priori, nine palliative opportunities were defined (disease progression or relapse, admission for symptoms, social concerns or end-of-life, intensive care or bone marrow transplant admission, phase 1 trial or hospice enrollment, do-not-resuscitate status). A single-center retrospective review was conducted on patients aged 0-18 years with bone/soft tissue sarcomas who died from January 1, 2012 to November 30, 2017. Demographic, disease, and treatment data were collected. Descriptive statistics were performed. Opportunities were evaluated over quartiles from diagnosis to death. RESULTS Patients (n = 60) had a mean of nine (SD = 4) palliative opportunities with the majority occurring in the last quartile of the disease course. Number and type of opportunities did not differ by demographics or diagnosis. Eighteen patients (30%) received PC consultation a median of 2.2 months (interquartile range [IQR] 11.5) prior to death. Consultation was unrelated to diagnosis or total opportunities. CONCLUSIONS Patients with sarcomas incur repeated events warranting subspecialty PC, which increase toward the end-of-life. Increased PC utilization may help decrease suffering and bolster family coping during these episodes. Additional work should further refine if opportunities differ across cancers, and how to incorporate this framework into clinical oncology care to prevent missed opportunities for PC.
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Affiliation(s)
| | - Kristen Allen
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nicholas DeGroote
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen Wasilewski-Masker
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Katharine E Brock
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, Georgia.,Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, Georgia
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Lewis EA. Optimizing the delivery of early palliative care for hematology patients receiving a stem cell transplant: A role for a Nurse Practitioner. Can Oncol Nurs J 2020; 30:239-245. [PMID: 33165367 DOI: 10.5737/23688076304239245] [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: 12/25/2022] Open
Abstract
A hematopoietic stem cell transplant (HSCT) is an intense treatment approach for patients with a hematologic malignancy and brings a significant risk for morbidity and mortality. HSCT brings hope of cure for patients; however, treatments are lengthy and burdensome from both a physical and psychosocial perspective. As the culture of HSCT has traditionally been cure-oriented, it leaves little room for a potential partnership with palliative care services, and when palliative care services are introduced, it is often too late for significant benefit. The need to standardize palliative care involvement for patients with hematologic malignancies receiving a HSCT has become necessary, yet there are challenges with the best way to create such a partnership. Nurse practitioners are a steadily growing professional body possessing the knowledge and skill necessary to fill the gap in palliative care delivery for HSCT patients. The proposed Nurse Practitioner Early Palliative Care for HSCT patients (NEST) algorithm will seek to provide a pathway in which to foster a partnership between hematology/HSCT teams and palliative services to yield the best care possible for patients.
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Affiliation(s)
- Ellen A Lewis
- Nurse Practitioner, Hematology, Tom Baker Cancer Centre, Foothills Medical Centre, AB,
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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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