Patients with haematological malignancies are being referred late to palliative care – most (72%) in the last 30 days of life and about a third in the last five days – or not at all (26%).
The findings, from an Australian study published in JNCCN [link here], suggest the need for an increased awareness of the role of specialist palliative care, the haematologist researchers say.
The Monash Health study reviewed the medical records of 259 patients with any haematological malignancy who died between October 1, 2019, and July 31, 2022,
Patients included those with AML (27%), aggressive lymphoma including DLBCL and Burkitt lymphoma (23%) and multiple myeloma (17.5%). Median age was 77 years, most patients were male (65%) and 58% were born outside Australia.
The study, led by Dr Briony Shaw from the Department of Clinical Haematology at Monash Health, found almost half (48%) of all patients received cytotoxic or targeted therapy within the 30 days prior to death.
Many (61%) received antibiotics in the last week of life and a similar proportion (61%) received a RBC transfusion in the last 30 days of life.
More than a fifth (22%) underwent an invasive procedure, including pleural drains, gastroscopies, and abscess drainage but excluding bone marrow biopsies, in the last 30 days of life. A similar proportion (22%) were admitted to ICU during the last 30 days of life.
Just over half of patients died in hospital (54%) – either in the haematology ward (37%), ICU (11%) or ED (6%).
“Thirty percent were transferred to the inpatient palliative care unit (hospice)—most transferred directly from the acute hospital—with a median length of stay of just 4 days from admission to death (range, 1–73 days; IQR, 10 [3–13] days).”
“One-fifth of all patients spent their last 30 days of life in the hospital (including hospice), and 40% spent their last 2 weeks of life in the hospital,” the study said.
A small minority of patients died at home (9%) or in residential aged care (7%).
The study found 52% of patients who were not referred to specialist palliative care were admitted to the ICU within the last 30 days of life, where 32% were intubated and 17% had noninvasive ventilation.
“These patients were also significantly more likely to receive antibiotics within 7 days of death.”
The study said early palliative care referral was increasingly used in solid cancer patients but was less established in patients with haematologic malignancy.
“Part of the challenge in identifying the end-of-life phase arise from the fact that patients with haematological malignancies may not have overt symptoms, such as uncontrolled pain, which traditionally triggers a referral to palliative care for specialist symptom management.”
“However, distressing symptoms are often present, and palliative care services provide other benefits in its holistic model of care, such as psychological support, family support, and bereavement follow-up.”
It called for the development of quality indicators for identifying end of life in patients with haematological malignancies.
“Without clear indicators of when to cease active therapy in those with disease progression or clinical deterioration, it is difficult to assess whether accessing chemotherapy, blood product transfusion, antibiotics, and/or invasive interventions is appropriate in the last days or weeks of life.”
The study found being enrolled in a clinical trial was associated with a significantly increased likelihood of receiving cytotoxic therapy and platelet transfusion in the 30 days prior to death.
“These patients were also significantly more likely to have an ICU admission and trended toward not having a resuscitation limitation (odds ratio [OR], 0.53; 95% CI, 0.26–1.08; P=.09).”