Hematologic Malignancy: Who Cares in the End? A Retrospective Cohort Study of Markers of Quality End-of-Life Care

Authors:
Briony Shaw Department of Clinical Haematology, Monash Health, Clayton, Victoria, Australia
Department of Supportive and Palliative Care, Monash Health, Clayton, Victoria, Australia
Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia

Search for other papers by Briony Shaw in
Current site
Google Scholar
PubMed
Close
 MBBS(Hons)
,
Catriona Parker Department of Supportive and Palliative Care, Monash Health, Clayton, Victoria, Australia
Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia

Search for other papers by Catriona Parker in
Current site
Google Scholar
PubMed
Close
 MAppSc(MedSc), PhD
,
Stephen Opat Department of Clinical Haematology, Monash Health, Clayton, Victoria, Australia
Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia

Search for other papers by Stephen Opat in
Current site
Google Scholar
PubMed
Close
 MBBS(Hons)
,
Jake Shortt Department of Clinical Haematology, Monash Health, Clayton, Victoria, Australia
Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia

Search for other papers by Jake Shortt in
Current site
Google Scholar
PubMed
Close
 MBChB, PhD
, and
Peter Poon Department of Supportive and Palliative Care, Monash Health, Clayton, Victoria, Australia
Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia

Search for other papers by Peter Poon in
Current site
Google Scholar
PubMed
Close
 MBBS, PGDipPM
Restricted access

Background: Early palliative care is increasingly used in solid organ malignancy but is less established in patients with hematologic malignancy. Disease-related factors increase the demand for hospitalization, treatment, and supportive care in patients with hematologic malignancy. The terminal phase of illness in patients with hematologic malignancy can be difficult to predict, resulting in complexities in establishing a standard for quality end-of-life care. Methods: This is a retrospective single-center cohort study of adult patients with hematologic malignancy who died between October 2019 and July 2022. Patients were identified, and disease characteristics, therapy, and outcomes were extracted from medical records. Descriptive statistics are reported and univariate analyses were performed across a range of factors to assess for associations. Results: A total of 229 patients were identified, with a median age of 77 years and 35% female. In the final 30 days of life, 65% presented to the emergency department, 22% had an ICU admission, 22% had an invasive procedure, 48% received cytotoxic therapy, 61% received a RBC transfusion, and 46% received a platelet transfusion. Use of intensive chemotherapy was particularly associated with hospitalization and ICU admission. A total of 74% referred to palliative care, with a median time from referral to death of 13 days. Of these patients, one-third were referred within the last 5 days of life. In terms of place of death, 54% died in the acute hospital setting and 30% in hospice, with a median hospice length of stay of 4 days. Conclusions: These findings highlight the need for further research into quality indicators for end of life in hematologic malignancy and earlier integration of specialist supportive and palliative care in both inpatient and outpatient settings.

Submitted January 31, 2023; final revision received March 26, 2023; accepted for publication April 25, 2023.

Author contributions: Study concept and design: Shaw, Poon. Data acquisition: Shaw. Data analysis and interpretation: All authors. Manuscript preparation: All authors.

Disclosures: The authors have disclosed that they have not received any financial considerations from any person or organization to support the preparation, analysis, results, or discussion of this article.

Correspondence: Briony Shaw, MBBS(Hons), Department of Clinical Haematology, Monasch Health, 246 Clayton Road, Clayton, Victoria 3168, Australia. Email: briony.shaw@monashhealth.org

Supplementary Materials

    • Supplemental Materials (PDF 414 KB)
  • Collapse
  • Expand
  • 1.

    Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733742.

  • 2.

    Bakitas MA, Tosteson TD, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol 2015;33:14381445.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Howell DA, Shellens R, Roman E, et al. Haematological malignancy: are patients appropriately referred for specialist palliative and hospice care? A systematic review and meta-analysis of published data. Palliat Med 2011;25:630641.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Manitta VJ, Philip JA, Cole-Sinclair MF. Palliative care and the hemato-oncological patient: can we live together? A review of the literature. J Palliat Med 2010;13:10211025.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Maddocks I, Bentley L, Sheedy J. Quality of life issues in patients dying from haematological diseases. Ann Acad Med Singap 1994;23:244248.

  • 6.

    Howell DA, Roman E, Cox H, et al. Destined to die in hospital? Systematic review and meta-analysis of place of death in haematological malignancy. BMC Palliat Care 2010;9:9.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    LeBlanc TW. Addressing end-of-life quality gaps in hematologic cancers: the importance of early concurrent palliative care. JAMA Intern Med 2016;176:265266.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    El-Jawahri A, LeBlanc TW, Kavanaugh A, et al. Effectiveness of integrated palliative and oncology care for patients with acute myeloid leukemia: a randomized clinical trial. JAMA Oncol 2021;7:238245.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Potenza L, Scaravaglio M, Fortuna D, Giusti D et al. Early palliative/ supportive care in acute myeloid leukaemia allows low aggression end-of-life interventions: observational outpatient study. BMJ Support Palliat Care. Published online November 8, 2021. doi:10.1136/bmjspcare-2021-002898

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Döhner H, Wei AH, Appelbaum FR, et al. Diagnosis and management of AML in adults: 2022 recommendations from an international expert panel on behalf of the ELN. Blood 2022;140:13451377.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Sehn LH, Berry B, Chhanabhai M, et al. The revised International Prognostic Index (R-IPI) is a better predictor of outcome than the standard IPI for patients with diffuse large B-cell lymphoma treated with R-CHOP. Blood 2007;109:18571861.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Gregory GP, Dickinson M, Yannakou CK, et al. Rapid and durable complete remission of refractory AITL with azacitidine treatment in absence of TET2 mutation or concurrent MDS. HemaSphere 2019;3:e187.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Fenaux P, Gobbi M, Kropf PL, et al. Results of ASTRAL-1 study, a phase 3 randomized trial of guadecitabine (G) vs treatment choice (TC) in treatment naïve acute myeloid leukemia (TN-AML) not eligible for intensive chemotherapy (IC). HemaSphere 2019;3(Suppl 1):Abstract S879.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Manitta V, Zordan R, Cole-Sinclair M, et al. The symptom burden of patients with hematological malignancy: a cross-sectional observational study. J Pain Symptom Manage 2011;42:432442.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Ramsenthaler C, Kane P, Gao W, et al. Prevalence of symptoms in patients with multiple myeloma: a systematic review and meta-analysis. Eur J Haematol 2016;97:416429.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Vaughn DM, Johnson PC, Jagielo AD, et al. Factors associated with health care utilization at the end of life for patients with acute myeloid leukemia. J Palliat Med 2022;25:749756.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Odejide OO, Uno H, Murillo A, et al. Goals of care discussions for patients with blood cancers: association of person, place, and time with end-of-life care utilization. Cancer 2020;126:515522.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Monash Health. Annual Report: 2021–2022. Accessed January 9, 2023. Available at: https://monashhealth.org/wp-content/uploads/2022/09/ MH-2021-22-Annual-Report_Digital-Accessible.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Waldrop DP, Meeker MA, Kutner JS. Is it the difference a day makes? Bereaved caregivers’ perceptions of short hospice enrollment. J Pain Symptom Manage 2016;52:187195.e1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Beaussant Y, Daguindau E, Chauchet A, et al. Hospital end-of-life care in haematological malignancies. BMJ Support Palliat Care 2018;8:314324.

  • 21.

    Caraceni A, Pellegrini C, Shkodra M, et al. Telemedicine for outpatient palliative care during COVID-19 pandemics: a longitudinal study. BMJ Support Palliat Care. Published online June 16, 2022. doi:10.1136/bmjspcare-2022-003585

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Tang M, Reddy A. Telemedicine and its past, present, and future roles in providing palliative care to advanced cancer patients. Cancers (Basel) 2022;14:1884.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Odejide OO, Cronin AM, Earle CC, et al. Why are patients with blood cancers more likely to die without hospice? Cancer 2017;123:33773384.

  • 24.

    Australian Bureau of Statistics. Classifying place of death in Australian mortality statistics: a pilot study applying a framework for the classification of place of death to the Australian mortality dataset. Accessed March 9, 2023. Available at: https://www.abs.gov.au/statistics/research/classifying-place-death-australian-mortality-statistics

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Cross SH, Warraich HJ. Changes in the place of death in the United States. N Engl J Med 2019;381:23692370.

  • 26.

    McCaughan D, Roman E, Smith AG, et al. Palliative care specialists’ perceptions concerning referral of haematology patients to their services: findings from a qualitative study. BMC Palliat Care 2018;17:33.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Sheridan R, Roman E, Smith AG, et al. Preferred and actual place of death in haematological malignancies: a report from the UK haematological malignancy research network. BMJ Support Palliat Care 2021;11:716.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Odejide OO, Salas Coronado DY, Watts CD, et al. End-of-life care for blood cancers: a series of focus groups with hematologic oncologists. J Oncol Pract 2014;10:e396403.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    LeBlanc TW, O’Donnell JD, Crowley-Matoka M, et al. Perceptions of palliative care among hematologic malignancy specialists: a mixed-methods study. J Oncol Pract 2015;11:e230238.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    LeBlanc TW, El-Jawahri A. When and why should patients with hematologic malignancies see a palliative care specialist? Hematology Am Soc Hematol Educ Program 2015;2015:471478.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Hudson KE, Wolf SP, Samsa GP, et al. The surprise question and identification of palliative care needs among hospitalized patients with advanced hematologic or solid malignancies. J Palliat Med 2018;21:789795.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Auret K, Bulsara C, Joske D. Australasian haematologist referral patterns to palliative care: lack of consensus on when and why. Intern Med J 2003;33:566571.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Shaulov A, Rodin G, Popovic G, et al. Pain in patients with newly diagnosed or relapsed acute leukemia. Support Care Cancer 2019;27:27892797.

  • 34.

    Hui D, Didwaniya N, Vidal M, et al. Quality of end-of-life care in patients with hematologic malignancies: a retrospective cohort study. Cancer 2014;120:15721578.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Button E, Gavin NC, Chan RJ, et al. Clinical indicators that identify risk of deteriorating and dying in people with a hematological malignancy: a case-control study with multivariable analysis. J Palliat Med 2018;21:17291740.

    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 2948 2948 63
PDF Downloads 1843 1843 65
EPUB Downloads 0 0 0