Blood cancers

Gut feeling isn’t enough to predict patient deaths

Six clinical indicators can help predict the likelihood of death within three months in patients with haematological malignancies, according to research presented at the HAA 2017 Annual Scientific Meeting in Sydney.

Nurse researcher Elise Button, from the Royal Brisbane and Women’s Hospital and Queensland Institute of Technology, said the findings would make it easier to know when to initiate end of life discussions.

Ms Button said treatment advances and the unpredictable trajectory of haematological cancers had made it difficult to transition from curative and life prolonging treatment to supportive and palliative care.

She told the limbic patients with haematological malignancies typically have higher rates of admission to ICU near their end of life, chemotherapy at end of life and more unplanned admissions than other patients with similar symptom burden.

“If they just use clinical judgment to identify when someone is nearing end of life, clinicians are often over-optimistic. Evidence shows it’s most effective to use clinical judgment plus a clinical tool.”

The retrospective case-control study found treatment limitations (OR 7.9), declining performance (OR 7.2), persistent bacterial and viral infections (OR 6.1), invasive fungal infections (OR 4.9), disease status (OR 3.7) and two or more comorbidities (OR 3.0) were all significant predictors of death.

“Even though we still need to do prospective testing and validate our findings, these prognostic markers can be used as a guide in conjunction with clinician expertise to identify when patients might be at risk of dying and when to start talking about patient preferences.”

“We’re not telling people to pull out of active treatment but to have the discussion in case something happens. Give people they opportunity to live the life they want in the time they have remaining. And if they don’t die – they may stabilise – there is

no harm in talking about end of life if it’s done sensitively.”

“Obviously doctors take a lead role in initiating those conversations but the whole multidisciplinary team – medical, nursing, allied health, social work – should play a role in knowing the signs of deterioration that should trigger sensitive discussions.”

“We all have the gut feeling but we need evidence behind that.”

Ms Button said clinical tools to predict death in other patient groups were often reliable out to 12 months.

“The shorter time period we’ve identified aligns with a haematological illness trajectory in that they do deteriorate rapidly. That makes clinical sense.”

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