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Intensive Palliative Care for Patients With Hematological Cancer Dying in Hospice: Analysis of the Level of Medical Care in the Final Week of Life
American Journal of Hospice & Palliative Medicine® 201X, Vol XX(X) 1–5 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113512412 ajhpm.sagepub.com
Benjamin Hon Wai Cheng, FHKCP, MRCP1,2, Michael Mau Kwong Sham, FRCP1, Kwok Ying Chan, FHKCP1, Cho Wing Li, FHKCP1, and Ho Yan Au, MRCP2
Abstract Dying of hematological oncology patients often take place in respective hematology ward or intensive care unit rather than hospice. With the increased attention to quality palliative care for hematology patients, concerns regarding their level of medical care at endof-life need to be addressed. We conducted a retrospective review of consecutive hematological oncology patients who succumbed in a palliative unit between July 2012 and August 2013. The primary outcome measure was their level of medical care received, including administration of antibiotics, total parenteral nutrition, blood sampling, GCSF injection and blood products transfusion, during their last seven days of life. During the last seven days of life, 85.7 % of patients had blood sampling and 23.8% of patients received G-CSF injection. Total parenteral nutrition was administered in 14.3% of patients. One-third of patients received transfusion of packed cells and nearly half of them received transfusion of platelet concentrates. Almost 90% of patients received antibiotics during their last week of life. Collaboration between hematology and palliative care has resulted in successful transition of hematologic cancer patients into hospice unit in their terminal phase of illness. However, their level of medical care, even approaching last seven days of life, remained intensive. Proper allocation of medical resources and future research regarding optimal end-of-life care for hematology patients are warranted. Keywords intensive, palliative care, hematology, oncology, dying, hospice
Introduction Hospice is intended to provide palliative care for patients with a terminal diagnosis and offer psychosocial support to them and their families. Despite significant advances in the treatment of hematological malignancies, many patients still die from their disease.1 However, patients with hematological cancer are referred to palliative care services less often than those with solid cancers,2,3 despite higher inpatient mortality4 and shorter interval between first consultation and death.5 One of the major challenges in caring for patients with hematological cancer is to decide when a referral to a palliative medical unit should take place. The difficulty in individual prognostication, ongoing therapeutic goals of curability, the technical nature and complications of treatment, and the speed of rapid change to a terminal event all possess difficulty and hinder referral.1 However, new definitions of palliative care highlight its justification from the patients’ palliative care needs, rather than a formal diagnosis of being terminally ill. Despite recent studies demonstrating an increase in numbers of hematology referrals and greater palliative care involvement
in hematology deaths,6 patients with hematological cancer often remained a distinct group in the setting of palliative care, with their final days of life spent in intensive care unit or hematology wards, rather than receiving specialized palliative care in hospice setting.7 Difficulties in the referral process includes hospice bed shortages, lack of knowledge of palliative care by hematologists, and, more importantly, the intensive level of medical support required in the later stages of illness of hematology patients.8 Palliative care of patients with hematological cancer needs to satisfy the highest medical standards and quality requirements, as patients often require regular blood tests,
1
Palliative Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Aberdeen, Hong Kong SAR, China 2 Department of Medicine, Queen Mary Hospital, Pok Fu Lam, Hong Kong SAR, China Corresponding Author: Benjamin Hon Wai Cheng, MRCP, Palliative Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Aberdeen, Hong Kong SAR, China. Email: [email protected]
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American Journal of Hospice & Palliative Medicine® XX(X)
2 Table 1. Demographic and Health Data of the Patients.a N Age Sex Female Male Marital status Married Widowed Divorced Accommodation Institution Alone With family members
%
Median 76
8 13
29.1 61.9
12 7 2
57.1 33.3 9.5
2 2 18
9.5 9.5 85.7 Mean 14.8
Days received hospice care, days
Range 34-91
SD 11.3
Time from first diagnosis, months Median Range Hematological malignancy AML Lymphoma Myeloma Chemotherapy within 3 months Presence of central venous catheter
7 6 8 15 7
33.3 28.6 38.1 71.4 33.3
8 12.5 8
5-40 6-33 3-34
Abbreviations: AML, acute myeloid leukemia; SD, standard deviation. a n ¼ 21.
transfusion of blood products, antibiotics administration as well as central catheter care. On the other hand, patients with hematological cancer do have complex psychosocial needs and significant symptom burden, which need to be addressed.1 Besides, the cotreatment of relatives and bereavement care are often included in palliative care goal. Currently, there are only very limited data in treatment characteristics of dying patients with hematological cancer in a hospice setting. Palliative medical unit (PMU) of Grantham Hospital, Hong Kong, had established collaboration with Hematology unit of Queen Mary Hospital, University of Hong Kong in the recent 2 years. The collaboration model includes joint round for patients with hematological cancer, home care visit by outreach nurses, and in-patient hospice care for patients with hematological cancer with complex psychosocial needs and end-of-life care. This study was carried out to identify the level of medical care received by dying patients with hematological cancer in their final week of life, aiming to improve palliative care of patients with hematological cancer in a PMU setting.
for general data, the analysis focused on the last 7 days of life of the included patients. Medical records of all identified patients would be reviewed retrospectively, with data collected including demographic variables, diagnoses at discharge, treatment history, antibiotics usage, and transfusion requirement in the last 7 days of care. The Palliative Medical Unit of Grantham Hospital is an accredited training center for the palliative medicine specialty in Hong Kong. The inpatient service consists of 44 palliative beds. It provides palliative care service to Hong Kong Island with a population of around 1.5 million. It has close collaboration with hematology unit of Queen Mary Hospital, which is a tertiary hematology unit and teaching hospital of University of Hong Kong. Service provided includes joint medical round, home care nurse visit for patients with hematological cancer, and inpatient hospice care. Collected data were analyzed with SPSS version 16.0 for Windows. The statistical significance level was set at P < .05 unless otherwise specified. Descriptive statistics were used to characterize the sociodemographic and clinical features of the whole sample. Means, standard deviations (SDs), and ranges for all scale variables measured in the study were calculated for patients.
Material and Methods All patients with hematological malignancies, who died in the palliative medical unit of Grantham Hospital, Hong Kong between July 2012 and August 2013, were included in this study, irrespective of the reasons and circumstances of their death. No exclusion criteria of any kind were applied. Except
Results During the study period, there were 39 patients with hematological cancer under inpatient palliative care. Of them, 21 succumbed in our unit and were included in the study. Patient
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Cheng et al
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Table 2. Level of Medical Care Received Within the Last Week of Life. N
%
Blood sampling 18 85.70 Granulocyte colony–stimulating factor (G-CSF) injection 5 23.80 Total parenteral nutrition (TPN) administration 3 14.30 Transfusion of red cells 7 33.30 Total number of units transfused ¼ 16 Total number of transfusion episode ¼ 8 Pretransfusion hemoglobin level (mean ¼ 7.8 g/dL, SD 1.4) Transfusion of platelet concentrates 10 47.60 Total number of units transfused ¼ 68 Total number of transfusion episode ¼ 17 Indication of transfusion: 3 for clinical bleeding; Fourteen as bleeding prophylaxis Pretransfusion platelet level (mean ¼ 9.3 109/L, SD 5.5) Antibiotics usage 19 90.50 Intravenous route ¼ 18 Oral route ¼ 1 Choice of antibiotics use Meropenam 5 Piperacillin/tazobactam 4 Timentin 3 Augmentin 3 Levofloxacin 3 Vancomycin 1 Abbreviation: SD, standard deviation.
characteristics are depicted in Table 1. There were 13 (61.9%) males and 8 (29.1%) females, with a median age of 76 years (34-91). All of the recruited patients were Chinese. On average, they received 14.8 (SD 11.3) days of inpatient care at our unit. Diagnoses included acute myeloid leukemia (AML; n ¼ 7, 33.3%), lymphoma (n ¼ 6, 28.6%), and multiple myeloma (n ¼ 8, 38.1%). The median time from first diagnosis for AML was 8 months (range 5-40 months), lymphoma 12.5 months (range 6-33 months), and multiple myeloma 8 months (range 3-34 months). In our study, one-third of patients with hematological cancer (n ¼ 7) transferred to hospice possessed central venous catheter. Within the previous 3 months of study, 71.4% (n ¼ 15) of patients received chemotherapy. Level of medical treatment recorded within the last 7 days (final week) of life was analyzed. Up to 85.7% (n ¼ 18) of patients received blood sampling, while 23.8% (n ¼ 5) were still on granulocyte colony–stimulating factor (G-CSF) injection. In all, 3 (14.3%) patients were maintained on total parenteral nutrition (TPN). One-third (n ¼ 7) of study population required the transfusion of red blood cells, while nearly half (n ¼ 10, 47.6%) of them received platelets. For the 21 patients included in our study, 16 units of red blood cells (8 episodes) and 68 units of platelet concentrates (17 episodes) were transfused in their final week of life. The mean pretransfusion hemoglobin level was 7.8 (standard deviation [SD] ¼ 1.4) g/dL, while the mean platelet count was 9.3 109/L (SD ¼ 5.5). Indication of platelet transfusion within the 17 episodes was analyzed, 3
transfusions were indicated for clinical bleeding while 14 episodes served as bleeding prophylaxis (Table 2). Approximately 91% (n ¼ 19) of our hospice patients with hematological cancer received antibiotic treatment in their final week of life. Majority of them was administered intravenously (n ¼ 18, 94.7%). Among patients who received antibiotics, meropenam (n ¼ 5, 23.8%) and piperacillin/tazobactam (n ¼ 4, 19.0%) were most frequently prescribed.
Discussion Due to the complexity of hematologic malignancies, intensified by the novel chemotherapeutic treatments, a wide variety of symptoms and complications do occur. Very often, there is a great impact on the well-being of patients due to the invasive diagnostic and invasive procedures, with significant risk of side effects and treatment burden.9 In our study population, around one-third of the patient was transferred to us with central venous catheter in situ, while more than two-third received chemotherapy in the previous 3 months. Because of the imminent bone marrow insufficiency and chemotherapy-induced leukopenia, our patients with hematological cancer are at risk of different infections. Previous autopsy study demonstrated that up to 61% of the deaths were due to infective complications.10 The use of antibiotics in palliative care setting, however, is controversial. Previous studies demonstrated that antibiotics did not have an impact on the survival of patients under palliative intent of treatment,11,12 but whether this could be generalized to patients with hematological cancer is awaited to be proved. In our study, significant number of patients was treated with broad-spectrum antibiotics, namely, meropenam and piperacillin/tazobactam. Majority were administered intravenously. As intravenous catheters, either central or peripheral, are a necessary prerequisite for antibiotics injection, these patients would undergo an elevated hardship of discomfort, complications, and cost. The decision to use antibiotics in hospice care is difficult and often complicated by physician, patient, and family beliefs.13 The probability of symptom improvement must be weighed against the burdens imposed on patient as well as the public health concerns regarding antibiotic resistance.14 Another aspect of concern was blood product usage in patients with hematological cancer under palliative care. Blood products are scarce resources requiring prudent and reasonable allocation. Currently there were few studies addressing blood product usage in end-of-life care. Our study revealed a significant transfusion requirement, even approaching their last week of life. Up to one-third of patients received packed cells and nearly half of them received platelet concentrates. As international consensus regarding blood product usage in end-of-life care is lacking, very often palliative care physicians depend on ethical principles in our decision making or continue the level of blood products support as patient was under curative treatment intent. Recently published article15 suggested that transfusions in medically futile situations should be avoided as far as possible and limited to the number of red blood cell transfusions necessary to ameliorate the symptoms of anemia. Platelet transfusions should also be limited to the
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American Journal of Hospice & Palliative Medicine® XX(X)
4 minimum necessary to control bleeding. In difficult situation in defining medical futility, guidelines suggested consultation with hospital ethics committee. In daily practice, however, not uncommonly blood products were given ‘‘empirically’’ when doctors responded to figures from complete blood picture rather than patients’ individual needs. Hematological malignancies are a heterogeneous group of cancers, comprising more than 50 subtypes.16 Disease trajectory varies from indolent cases, showing no progression for many years, up to very aggressive conditions leading to guarded prognosis.17 In our study, patients included were found to have a short median survival from first diagnosis, especially for diagnostic groups such as lymphoma and multiple myeloma, in contrary to our knowledge that these group of patients usually survive up to years. This is related to the advanced age of treatment group under our care, with 9 of 14 in the lymphoma and myeloma group aged above 70 (*65%). Therapy in elderly patients needs special attention because older patients usually have several comorbidities with impaired physiological reserve. In fact, older patients treated for hematological malignancies may not tolerate the high-dose therapies used in younger patients and have increased risk of therapy-related toxicity.18 In our study, the average length of stay was 14.8 days in hospice before death, in agreement with the known delayed referral for patients with hematological cancer. The dying trajectory of patients with hematological cancer, in fact, is not necessarily comparable to the solid cancer group of patients. Patients with hematological cancer typically have acute exacerbations of illness interspersed with highly technical therapies that can continue over many years, with a more rapid dying phase once in the palliative phase of treatment.5,7,19 This clinical scenario may result in difficulty in determining the right time to engage palliative team support and referral to hospice care. The main limitation of our study lies in the small number of participants in a single palliative care unit, although consecutive patients were recruited to minimize selection bias. Despite these limitations, this is the first study to examine the level of medical treatment required for patients with hematological cancer in their last 7 days of life under hospice setting. Previous studies examining end-of-life care for patients with hematological cancer have been limited to hematology ward or intensive care unit.6,7,20 In conclusion, providing palliative care for patients with hematological cancer in a hospice setting is never an easy task. We should focus on good symptoms palliation, psychosocial support, and spiritual care for all patients under hospice care. Moreover, the level of medical treatment, even in those approaching end of life, is often intensive, which includes frequent blood sampling for count monitoring, G-CSF administration, central venous catheter care, injection of antibiotics, TPN administration, transfusion of blood products, and management of different treatment complications. We believe that adequate allocation of resources, formal training for palliative care workers, formulation of clinical guidelines regarding antibiotics usage, and blood product allocation are of utmost importance, in order to improve our standard of palliative care for patients with hematological cancer. We hope that hospital administrators and public will eventually acknowledge
the significant resource requirement and increasing role of palliative care in our patients with advanced hematological cancer. Acknowledgments The authors would like to acknowledge Professor Albert Lie, Head, Department of Medicine, Queen Mary Hospital, University of Hong Kong; and Professor YL Kwong, Division Chief of Hematology Unit, Queen Mary Hospital, University of Hong Kong, for their support and advice on the management of hematology patients under palliative care.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. 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(8):1021-1025. 2. McGrath P. Qualitative findings on the experience of end-of-life care for haematological malignancies. Am J Hosp Palliat Care. 2002;19(2):103-111. 3. Hunt RW, Fazekas BS, Luke CG, Priest KR, Roder DM. The coverage of cancer patients by designated palliative services: a population-based study, South Australia, 1999. Palliat Med. 2002;16(5):403-409. 4. Bruera E, Russel N, Sweeney C, Fisch M, Palmer JL: Place of death and its predictors for local patients registered at a comprehensive cancer centre. J Clin Oncol. 2002;20(8):2127-2133. 5. Cheng WW, Willey J, Palmer JL, Zhang T, Bruera E. Interval between palliative care referral and death among patients treated at a comprehensive cancer centre. J Palliat Med. 2005;8(5): 1025-1032. 6. Corbett CL, Johnstone M, Trauer JM, Spruyt O. Palliative care and hematological malignancies: increased referrals at a comprehensive cancer centre. J Palliat Med. 2013;16(5):537-541. 7. McGrath P, Holewa H. Special considerations for haematology patients in relation to end-of-life care: Australian findings. Eur J Cancer Care. 2007;16(2):164-171. 8. Bauder F, Capdupuy C, Renoux M. Characteristics of deaths in a department of oncohaematology from a general hospital: a study of 81 cases. Support Care Cancer. 2000;8(4):302-306. 9. Strasser F, Blum D, Bueche D. Invasive palliative interventions: when are they worth it and when are they not? Cancer J. 2010; 16(5):483-487. 10. Nosari A, Barberis M, Landonio G, et al. Infections in haematologic neoplasms: autopsy findings. Haematologica. 1991;76(2): 135-140. 11. Reinbolt RE, Shenk AM, White PH, Navari RM. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manage. 2005;30(2): 175-182.
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12. White PH, Kuhlenschmidt HL, Vancura BG, Navari RM. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manage. 2003;25(5):438-443. 13. Albrecht JS, McGregor JC, Fromme EK, Bearden DT, Furuno JP. A Nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage. 2013;46(4): 483-490. 14. Benjamin Cheng HW, Sham MK, Chan KY. Emergence of Vancomycin-Resistant Enterococci in the Palliative Care Setting—How to Strike the Right Balance in Infection Control Measures? J Pain Symptom Manage. 2013, November 6. doi:10.1016/j.jpainsymman.2013.10.007. [Epub ahead of print] 15. Smith LB, Cooling L, Davenport R. How do I allocate blood products at the end of life? an ethical analysis with suggested guidelines. Transfusion. 2013;53(4):696-700.
16. Fritz A, Percy C, Jack A, et al. International Classification of Diseases for Oncology, 3 rd ed. Geneva, Switzerland: World Health Organization, 2000. 17. Doorduijn JK, Kluin-Nelemans HC. Management of mantle cell lymphoma in the elderly patient. Clin Interv Aging. 2013;8: 1229-1236. 18. Kluin-Nelemans HC, Hoster E, Hermine O, et al. Treatment of older patients with mantle cell lymphoma. N Engl J Med. 2012; 367(6):520-531. 19. Auret K, Bulsara C, Joske D. Australian haematologist referral patterns to palliative care: lack of consensus on when and why. Intern Med J. 2003;33(12):566-571. 20. Bru¨ck P, Pierzchlewska M, Kaluzna-Oleksy M, et al. Dying of hematologic patients – Treatment characteristics in a German University Hospital. Support Care Cancer. 2012;20(11):2895-2902.
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Intensive Palliative Care for Patients With Hematological Cancer Dying in Hospice: Analysis of the Level of Medical Care in the Final Week of Life
American Journal of Hospice & Palliative Medicine® 201X, Vol XX(X) 1–5 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113512412 ajhpm.sagepub.com
Benjamin Hon Wai Cheng, FHKCP, MRCP1,2, Michael Mau Kwong Sham, FRCP1, Kwok Ying Chan, FHKCP1, Cho Wing Li, FHKCP1, and Ho Yan Au, MRCP2
Abstract Dying of hematological oncology patients often take place in respective hematology ward or intensive care unit rather than hospice. With the increased attention to quality palliative care for hematology patients, concerns regarding their level of medical care at endof-life need to be addressed. We conducted a retrospective review of consecutive hematological oncology patients who succumbed in a palliative unit between July 2012 and August 2013. The primary outcome measure was their level of medical care received, including administration of antibiotics, total parenteral nutrition, blood sampling, GCSF injection and blood products transfusion, during their last seven days of life. During the last seven days of life, 85.7 % of patients had blood sampling and 23.8% of patients received G-CSF injection. Total parenteral nutrition was administered in 14.3% of patients. One-third of patients received transfusion of packed cells and nearly half of them received transfusion of platelet concentrates. Almost 90% of patients received antibiotics during their last week of life. Collaboration between hematology and palliative care has resulted in successful transition of hematologic cancer patients into hospice unit in their terminal phase of illness. However, their level of medical care, even approaching last seven days of life, remained intensive. Proper allocation of medical resources and future research regarding optimal end-of-life care for hematology patients are warranted. Keywords intensive, palliative care, hematology, oncology, dying, hospice
Introduction Hospice is intended to provide palliative care for patients with a terminal diagnosis and offer psychosocial support to them and their families. Despite significant advances in the treatment of hematological malignancies, many patients still die from their disease.1 However, patients with hematological cancer are referred to palliative care services less often than those with solid cancers,2,3 despite higher inpatient mortality4 and shorter interval between first consultation and death.5 One of the major challenges in caring for patients with hematological cancer is to decide when a referral to a palliative medical unit should take place. The difficulty in individual prognostication, ongoing therapeutic goals of curability, the technical nature and complications of treatment, and the speed of rapid change to a terminal event all possess difficulty and hinder referral.1 However, new definitions of palliative care highlight its justification from the patients’ palliative care needs, rather than a formal diagnosis of being terminally ill. Despite recent studies demonstrating an increase in numbers of hematology referrals and greater palliative care involvement
in hematology deaths,6 patients with hematological cancer often remained a distinct group in the setting of palliative care, with their final days of life spent in intensive care unit or hematology wards, rather than receiving specialized palliative care in hospice setting.7 Difficulties in the referral process includes hospice bed shortages, lack of knowledge of palliative care by hematologists, and, more importantly, the intensive level of medical support required in the later stages of illness of hematology patients.8 Palliative care of patients with hematological cancer needs to satisfy the highest medical standards and quality requirements, as patients often require regular blood tests,
1
Palliative Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Aberdeen, Hong Kong SAR, China 2 Department of Medicine, Queen Mary Hospital, Pok Fu Lam, Hong Kong SAR, China Corresponding Author: Benjamin Hon Wai Cheng, MRCP, Palliative Medical Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Aberdeen, Hong Kong SAR, China. Email: [email protected]
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American Journal of Hospice & Palliative Medicine® XX(X)
2 Table 1. Demographic and Health Data of the Patients.a N Age Sex Female Male Marital status Married Widowed Divorced Accommodation Institution Alone With family members
%
Median 76
8 13
29.1 61.9
12 7 2
57.1 33.3 9.5
2 2 18
9.5 9.5 85.7 Mean 14.8
Days received hospice care, days
Range 34-91
SD 11.3
Time from first diagnosis, months Median Range Hematological malignancy AML Lymphoma Myeloma Chemotherapy within 3 months Presence of central venous catheter
7 6 8 15 7
33.3 28.6 38.1 71.4 33.3
8 12.5 8
5-40 6-33 3-34
Abbreviations: AML, acute myeloid leukemia; SD, standard deviation. a n ¼ 21.
transfusion of blood products, antibiotics administration as well as central catheter care. On the other hand, patients with hematological cancer do have complex psychosocial needs and significant symptom burden, which need to be addressed.1 Besides, the cotreatment of relatives and bereavement care are often included in palliative care goal. Currently, there are only very limited data in treatment characteristics of dying patients with hematological cancer in a hospice setting. Palliative medical unit (PMU) of Grantham Hospital, Hong Kong, had established collaboration with Hematology unit of Queen Mary Hospital, University of Hong Kong in the recent 2 years. The collaboration model includes joint round for patients with hematological cancer, home care visit by outreach nurses, and in-patient hospice care for patients with hematological cancer with complex psychosocial needs and end-of-life care. This study was carried out to identify the level of medical care received by dying patients with hematological cancer in their final week of life, aiming to improve palliative care of patients with hematological cancer in a PMU setting.
for general data, the analysis focused on the last 7 days of life of the included patients. Medical records of all identified patients would be reviewed retrospectively, with data collected including demographic variables, diagnoses at discharge, treatment history, antibiotics usage, and transfusion requirement in the last 7 days of care. The Palliative Medical Unit of Grantham Hospital is an accredited training center for the palliative medicine specialty in Hong Kong. The inpatient service consists of 44 palliative beds. It provides palliative care service to Hong Kong Island with a population of around 1.5 million. It has close collaboration with hematology unit of Queen Mary Hospital, which is a tertiary hematology unit and teaching hospital of University of Hong Kong. Service provided includes joint medical round, home care nurse visit for patients with hematological cancer, and inpatient hospice care. Collected data were analyzed with SPSS version 16.0 for Windows. The statistical significance level was set at P < .05 unless otherwise specified. Descriptive statistics were used to characterize the sociodemographic and clinical features of the whole sample. Means, standard deviations (SDs), and ranges for all scale variables measured in the study were calculated for patients.
Material and Methods All patients with hematological malignancies, who died in the palliative medical unit of Grantham Hospital, Hong Kong between July 2012 and August 2013, were included in this study, irrespective of the reasons and circumstances of their death. No exclusion criteria of any kind were applied. Except
Results During the study period, there were 39 patients with hematological cancer under inpatient palliative care. Of them, 21 succumbed in our unit and were included in the study. Patient
Downloaded from ajh.sagepub.com at TULANE UNIV on January 14, 2015
Cheng et al
3
Table 2. Level of Medical Care Received Within the Last Week of Life. N
%
Blood sampling 18 85.70 Granulocyte colony–stimulating factor (G-CSF) injection 5 23.80 Total parenteral nutrition (TPN) administration 3 14.30 Transfusion of red cells 7 33.30 Total number of units transfused ¼ 16 Total number of transfusion episode ¼ 8 Pretransfusion hemoglobin level (mean ¼ 7.8 g/dL, SD 1.4) Transfusion of platelet concentrates 10 47.60 Total number of units transfused ¼ 68 Total number of transfusion episode ¼ 17 Indication of transfusion: 3 for clinical bleeding; Fourteen as bleeding prophylaxis Pretransfusion platelet level (mean ¼ 9.3 109/L, SD 5.5) Antibiotics usage 19 90.50 Intravenous route ¼ 18 Oral route ¼ 1 Choice of antibiotics use Meropenam 5 Piperacillin/tazobactam 4 Timentin 3 Augmentin 3 Levofloxacin 3 Vancomycin 1 Abbreviation: SD, standard deviation.
characteristics are depicted in Table 1. There were 13 (61.9%) males and 8 (29.1%) females, with a median age of 76 years (34-91). All of the recruited patients were Chinese. On average, they received 14.8 (SD 11.3) days of inpatient care at our unit. Diagnoses included acute myeloid leukemia (AML; n ¼ 7, 33.3%), lymphoma (n ¼ 6, 28.6%), and multiple myeloma (n ¼ 8, 38.1%). The median time from first diagnosis for AML was 8 months (range 5-40 months), lymphoma 12.5 months (range 6-33 months), and multiple myeloma 8 months (range 3-34 months). In our study, one-third of patients with hematological cancer (n ¼ 7) transferred to hospice possessed central venous catheter. Within the previous 3 months of study, 71.4% (n ¼ 15) of patients received chemotherapy. Level of medical treatment recorded within the last 7 days (final week) of life was analyzed. Up to 85.7% (n ¼ 18) of patients received blood sampling, while 23.8% (n ¼ 5) were still on granulocyte colony–stimulating factor (G-CSF) injection. In all, 3 (14.3%) patients were maintained on total parenteral nutrition (TPN). One-third (n ¼ 7) of study population required the transfusion of red blood cells, while nearly half (n ¼ 10, 47.6%) of them received platelets. For the 21 patients included in our study, 16 units of red blood cells (8 episodes) and 68 units of platelet concentrates (17 episodes) were transfused in their final week of life. The mean pretransfusion hemoglobin level was 7.8 (standard deviation [SD] ¼ 1.4) g/dL, while the mean platelet count was 9.3 109/L (SD ¼ 5.5). Indication of platelet transfusion within the 17 episodes was analyzed, 3
transfusions were indicated for clinical bleeding while 14 episodes served as bleeding prophylaxis (Table 2). Approximately 91% (n ¼ 19) of our hospice patients with hematological cancer received antibiotic treatment in their final week of life. Majority of them was administered intravenously (n ¼ 18, 94.7%). Among patients who received antibiotics, meropenam (n ¼ 5, 23.8%) and piperacillin/tazobactam (n ¼ 4, 19.0%) were most frequently prescribed.
Discussion Due to the complexity of hematologic malignancies, intensified by the novel chemotherapeutic treatments, a wide variety of symptoms and complications do occur. Very often, there is a great impact on the well-being of patients due to the invasive diagnostic and invasive procedures, with significant risk of side effects and treatment burden.9 In our study population, around one-third of the patient was transferred to us with central venous catheter in situ, while more than two-third received chemotherapy in the previous 3 months. Because of the imminent bone marrow insufficiency and chemotherapy-induced leukopenia, our patients with hematological cancer are at risk of different infections. Previous autopsy study demonstrated that up to 61% of the deaths were due to infective complications.10 The use of antibiotics in palliative care setting, however, is controversial. Previous studies demonstrated that antibiotics did not have an impact on the survival of patients under palliative intent of treatment,11,12 but whether this could be generalized to patients with hematological cancer is awaited to be proved. In our study, significant number of patients was treated with broad-spectrum antibiotics, namely, meropenam and piperacillin/tazobactam. Majority were administered intravenously. As intravenous catheters, either central or peripheral, are a necessary prerequisite for antibiotics injection, these patients would undergo an elevated hardship of discomfort, complications, and cost. The decision to use antibiotics in hospice care is difficult and often complicated by physician, patient, and family beliefs.13 The probability of symptom improvement must be weighed against the burdens imposed on patient as well as the public health concerns regarding antibiotic resistance.14 Another aspect of concern was blood product usage in patients with hematological cancer under palliative care. Blood products are scarce resources requiring prudent and reasonable allocation. Currently there were few studies addressing blood product usage in end-of-life care. Our study revealed a significant transfusion requirement, even approaching their last week of life. Up to one-third of patients received packed cells and nearly half of them received platelet concentrates. As international consensus regarding blood product usage in end-of-life care is lacking, very often palliative care physicians depend on ethical principles in our decision making or continue the level of blood products support as patient was under curative treatment intent. Recently published article15 suggested that transfusions in medically futile situations should be avoided as far as possible and limited to the number of red blood cell transfusions necessary to ameliorate the symptoms of anemia. Platelet transfusions should also be limited to the
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American Journal of Hospice & Palliative Medicine® XX(X)
4 minimum necessary to control bleeding. In difficult situation in defining medical futility, guidelines suggested consultation with hospital ethics committee. In daily practice, however, not uncommonly blood products were given ‘‘empirically’’ when doctors responded to figures from complete blood picture rather than patients’ individual needs. Hematological malignancies are a heterogeneous group of cancers, comprising more than 50 subtypes.16 Disease trajectory varies from indolent cases, showing no progression for many years, up to very aggressive conditions leading to guarded prognosis.17 In our study, patients included were found to have a short median survival from first diagnosis, especially for diagnostic groups such as lymphoma and multiple myeloma, in contrary to our knowledge that these group of patients usually survive up to years. This is related to the advanced age of treatment group under our care, with 9 of 14 in the lymphoma and myeloma group aged above 70 (*65%). Therapy in elderly patients needs special attention because older patients usually have several comorbidities with impaired physiological reserve. In fact, older patients treated for hematological malignancies may not tolerate the high-dose therapies used in younger patients and have increased risk of therapy-related toxicity.18 In our study, the average length of stay was 14.8 days in hospice before death, in agreement with the known delayed referral for patients with hematological cancer. The dying trajectory of patients with hematological cancer, in fact, is not necessarily comparable to the solid cancer group of patients. Patients with hematological cancer typically have acute exacerbations of illness interspersed with highly technical therapies that can continue over many years, with a more rapid dying phase once in the palliative phase of treatment.5,7,19 This clinical scenario may result in difficulty in determining the right time to engage palliative team support and referral to hospice care. The main limitation of our study lies in the small number of participants in a single palliative care unit, although consecutive patients were recruited to minimize selection bias. Despite these limitations, this is the first study to examine the level of medical treatment required for patients with hematological cancer in their last 7 days of life under hospice setting. Previous studies examining end-of-life care for patients with hematological cancer have been limited to hematology ward or intensive care unit.6,7,20 In conclusion, providing palliative care for patients with hematological cancer in a hospice setting is never an easy task. We should focus on good symptoms palliation, psychosocial support, and spiritual care for all patients under hospice care. Moreover, the level of medical treatment, even in those approaching end of life, is often intensive, which includes frequent blood sampling for count monitoring, G-CSF administration, central venous catheter care, injection of antibiotics, TPN administration, transfusion of blood products, and management of different treatment complications. We believe that adequate allocation of resources, formal training for palliative care workers, formulation of clinical guidelines regarding antibiotics usage, and blood product allocation are of utmost importance, in order to improve our standard of palliative care for patients with hematological cancer. We hope that hospital administrators and public will eventually acknowledge
the significant resource requirement and increasing role of palliative care in our patients with advanced hematological cancer. Acknowledgments The authors would like to acknowledge Professor Albert Lie, Head, Department of Medicine, Queen Mary Hospital, University of Hong Kong; and Professor YL Kwong, Division Chief of Hematology Unit, Queen Mary Hospital, University of Hong Kong, for their support and advice on the management of hematology patients under palliative care.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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