Blood cancers

Pandemic pushes haematologists into having earlier discussions with patients on EOL care

For haematologists in the UK, the pressures on ICU beds from the COVID-19 pandemic has forced clinicians to think hard about the conversations they have with patients about treatment decisions for blood cancers.

Clinicians should be opening up discussions much earlier with patients about what level of intervention they would want if their condition deteriorates, the British Society for Haematology 2020 Virtual conference has heard.

Kate Rogers, a senior haematology clinical nurse specialist and Naomi Dean, a post transplant clinical nurse specialist at University Hospitals Birmingham told the conference that DNA-CPR decisions have become the ‘elephant in the room’

But earlier discussions have proven useful and now need to be embedded in routine practice, they told the virtual meeting.

They said the two questions that should be embedded into routine practice, even when COVID-19 has passed, are: ‘have you considered what might happen to you if you suddenly become more unwell? and ‘if you become too unwell to talk to us, what would your wishes be?’

“Our recommendations would be that we should start these discussions, early, particularly if we can have them in a controlled outpatient environment where we don’t need to make snap decisions.”

“We can talk about the pros and cons of what of what each concept might mean whether it means intensive care and ventilation and CPR, what that actually physically involves compared compared to a more palliative supportive approach. I think it’s important that we normalise these conversations,” they told the meeting.

They explained that despite being one of the largest transplant centres in the UK also running a CAR-T programme, historically they had no routine discussions on ceiling of care or wishes around resuscitation when a patient was diagnosed or if they were being admitted for a stem-cell transplant.

With a large intensive care unit and a curative treatment approach for most patients, this wasn’t felt to be necessary.

It meant that those conversations were only happening when a patient or family was at a “crisis” point, often out of hours when it was left to junior doctors.

When the pandemic hit and intensive care capacity became a potential problem they started to incorporate those “difficult” DNA-CPR discussions into the treatment consent process.

While it may not be appropriate for every patient and it would mean time spent on staff training, their take home message was that it needed to be “a routine, normal part of our care”.

They also said it was important to acknowledge that it can be very difficult staff to have these conversations “because we want to hope for the best for our patients”.

“Early discussion will set patient expectation and we can then manage those expectations, and it will also may lead to a clear patient pathway for staff caring for patients our followers,” they added.

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