“Palliating the Leukemia/BMT Patient: Challenges and Tips”med-fom-fpit.sites.olt.ubc.ca/files/2015/12/3.-Drs-Rodrigo-and-Yeom… · Judith Rodrigo MD FRCPC Wendy Yeomans MD MCFP

“Palliating the Leukemia/BMT

Patient: Challenges and Tips”

Judith Rodrigo MD FRCPC

Wendy Yeomans MD MCFP CAC

December 7, 2015

Objectives:

1) To understand the current status and disease trajectory for patients with hematological illnesses

2) To identify the barriers and possible solutions to quality end of life care for this patient population

3) To identify opportunities to introduce a palliative approach to care and look at appropriate interventions and care requirements at each stage of the illness

Outline

1. A palliative approach to care is emerging as an integrated component of comprehensive oncology care

2. Markers of poor quality EOL care – …and the literature suggesting that

patients with blood cancers receive poor EOL care

3. Possible explanations why

4. A VGH approach – Dr. Yeomans

5. Practical tips for palliating L/BMT patients

Policy Statements: Early palliative

care is part of comprehensive cancer

care • UK NHS 2003

– “Palliative care services and heamato-oncology should together provide integrated care for patients with haematological cancers from the time of diagnosis”

• US NQF 2012

– “Effective Palliative care is best achieved through partnerships (with medical specialties) from diagnosis to the end stage of illness”

• WHO 2007

– “Palliative care should be provided from the time of diagnosis of life-threatening illness …and adapt to the needs of the patient as the disease progresses”

• ASCO 2009, 2012

– “Further efforts are needed to realize the integration of palliative care in the model and vision of comprehensive cancer care by 2020”

• ASH??

Indicators of Poor Quality EOL Care

Indicator Specific measure

Underuse of Palliative Care Expertise Receipt of any form of specialist

palliative care

Underuse or Late Hospice Referral

No hospice referral or hospice

stay < 3 days

Place of Death

Death on an acute medical unit

Death in the ICU

Aggressive Acute, In-hospital care Near

Death

In last 30d of life:

Any ER visit

Any hospital admission

>14 days hospitalization

ICU admission

Inadequate Pain and Other Symptom

Control

Outcomes on SAS (eg ESAS)

Overuse of Chemotherapy Therapy within 14 days of death

Adapted from J Clin Oncol 2003; 21: 1133-1138



Underuse of Palliative Care Expertise Receipt of any form of

specialist palliative care



stay < 3 days

Place of Death


Death in the ICU


Death


Any ER visit



ICU admission


Control

Outcomes on SAS, (eg ESAS)



Our Patients are Less than Half as Likely

to be Referred to Palliative Care than

Those with Other Cancers

J Palliat Med 2010; 25(6); 630-641

0.46 (0.42-0.50)

Risk

Estimate (95% CI)

1

Our Patients are Less than Half as Likely to be

Referred to Palliative Care than Those with

Other Cancers

18% of hematologic

malignancy patients had

access to PC services

VS

44% of solid tumour

patients had access to

PC services

J Palliat Med 2007; 10:1146-1152

P < 0.001 Heme

Solid tumours

N=1453 deaths over

2003/04




palliative care



stay < 3 days

Place of Death


Death in the ICU


Death


Any ER visit



ICU admission


Control




Our Patients are Referred Later to

Hospice and Are More Sick When They

Get There

J Pain Symptom Manag 2015;49:505-512

% Worse

PPS

Shorter

stay

Five years CHOICE

Hospice data

Heme Solid




palliative care



stay < 3 days

Place of Death

Death on an acute medical

unit

Death in the ICU


Death


Any ER visit



ICU admission


Control




Most People Want to Die at Home

BMC Palliative Care 2013, 12:7 N>100 000 from 33 countries

Hematology Patients are More Likely to Die in

Hospital than those with Other Cancers

BMC Palliative Care 2010, 9:9

2.25 (2.07-2.44)

Risk

Estimate (95% CI)

1

Total of >30 000

hematology patients




palliative care



stay < 3 days

Place of Death


Death in the ICU

Aggressive Acute, In-hospital care

Near Death


Any ER visit



ICU admission


Control


Overuse of Chemotherapy Therapy within 14 days of

death


Aggressive EOL Care for

Patients with Hematologic

Malignancies • Aggressive EOL care was assessed by 6

indicators in the last month of life

• Composite score from 0 – 6 obtained

• In the last 30 days of life: – ≥ 2 ER visits

– ≥ 2 hospital admissions

– > 14 days hospitalization

– An ICU admission

– Death in hospital

– Use of chemotherapy

• The higher the score, the more aggressive the care

Cancer 2014; 120:1572-8

Cancer 2014; 120:1572-8

Heme pts got

more aggressive

care by all

markers

A Canadian Perspective..

J Clin Oncol 2011 29: 1587-1591

Heme malignancy

most predictive

factor of

aggressive care

Cancer deaths 1993-2004

N=227 000

Usual markers of

aggressive EOL care:

ED visits, hospitalizations,

ICU stay, chemotherapy




palliative care



stay < 3 days

Place of Death


Death in the ICU


Death


Any ER visit



ICU admission


Control




Symptom Burden in Hematology

Patients Referred to Palliative Care is

High SYMPTOMS IN HEMATOLOGIC MALIGNANCIES 425

Patients with hematologic malignancies were more

likely to be drowsy and confused than were patients

with solid malignancies. Therefore, we believe that

palliative care specialists need to be particularly vigi-

lant about treating symptoms of drowsiness and delir-

ium in these patients. Unfortunately due to the retro-

spective nature of the study we were not able to

determine the factors contributing to the high inci-

dence of delirium in these patients. The etiology of

this syndrome is usually multifactorial including med-

ications, infections, electrolyte abnormalities, brain

metastasis and cytokines release.29–31 Another possi-

ble explanation for the high incidence of delirium in

hematologic malignancy patients in our study is that

these patients were at a later stage of their illness at

the time of APCS, since delirium is more common near

the end of life.32 Future research should be aimed at

determining the incidence as well as the etiology of

delirium in these patients.

The survival of patients with hematologic malig-

nancies, a median of 13 days, was about one third of

that in patients with solid tumors at the time of APCS.

This finding suggests that end-of-life discussions

should be accelerated in patients with hematologic ma-

lignancies on their referral to palliative care services.

Furthermore, the short length of survival of these pa-

tients from the time of APCS combined with the fact

that they are likely to be confused and unable to make

end-of-life decisions further suggest that their care-

givers are experiencing a considerable amount of dis-

tress and therefore require extensive counseling and

anticipatory bereavement support. The reasons for the

late APCS in these patients are not well understood.

Other studies suggested that the high-tech needs of

these patients such as blood transfusions, which are

not usually provided in hospice services, can play a

role.33,34 However, due to the acute nature of our in-

patient palliative care unit where these treatments are

readily available16 it is likely that this had a lower im-

pact on APCS at our institution.

Our findings agree with those reported by Cheng et

al.3 that younger patients with solid tumors are more

likely than older patients to be referred early for pal-

liative care. We found no correlation between early re-

ferral to palliative care and symptom severity in either

group. This raises the possibility that strategies aimed

at increasing early APCS should place greater em-

phasis on advance care planning than on early symp-

tom control.

This study showed that the symptom burden was

high on referral to palliative care regardless of the

PC1-D interval, but this does not necessarily mean that

hematologists and oncologists under recognize ongo-

ing distress in these patients. Since one of the major

reasons for referral to palliative care at our institution

is interactable symptoms,15 it is possible that these pa-

tients were referred to palliative care primarily because

of their high level of distress and that those who were

not referred had a lower symptom burden. This is an

important area that will need to be addressed in

prospective longitudinal studies.

Furthermore, our study did not attempt to deter-

mine the symptom burden throughout the illness

trajectory in these populations. The only way to de-

termine this accurately is to conduct a study prospec-

tively in consecutive patients with solid and hemato-

logic malignancies and compare the symptom burden

at different points during their illness trajectory. This

is an important area that future research should focus

on in an attempt to identify opportunities for referral

of these patients to palliative care services. In addi-

tion, it might be difficult to compare these two groups

of patients because of the inherent differences in their

illness trajectories and therapeutic strategies resulting

in different end of life experiences. These differences

are important to consider in future research when

comparing these two groups of patients. Future re-

search should also attempt to identify models of care

that are capable of addressing the specific needs of

patients with hematologic malignancies to provide

earlier APCS.

Our study had several limitations. First, the retro-

spective nature of our data collection and analysis is

itself a limitation. Second, we collected the data for

only patients who had been referred to the palliative

care service, and this might not be representative of

other patients in both groups. However, this structured

level of symptom assessment utilizing the ESAS and

TABLE 2. SYMPTOM SEVERITY IN PATIENTS

BY TYPE OF MALIGNANCY

ESAS symptom Hematologic Solid p

Pain 4 (3–5) 5 (4–6) 0.043Fatigue 6 (6–7) 7 (6–7) 0.37Nausea 1 (0–3) 1 (0–2) 0.73Depression 2 (1–4) 3 (1–3) 0.45Anxiety 2.5 (1–4) 3 (3–4) 0.16Drowsiness 7 (5–10) 5 (3–6) 0.0008Appetite 5 (4–6) 5 (4–6) 0.93Well-being 5 (3–5) 4.5 (4–6) 0.83Dyspnea 2.5 (2–4) 3 (2–3) 0.86Sleep 5 (4–6) 4 (3–5) 0.31Delirium (%) 51/125 (41%) 20/125 (16%) 0.0001

Note: Data are given as median values (95% confidence interval [CI]) unless otherwise stated.

ESAS, Edmonton Symptom Assessment System.

J Pall Med 2008; 11:3:422-427

Heme, N=125 Solid, N=125

Symptoms assessed at

time of referral to PC

So what does EOL look like for

our patients?

• Half the rate of palliative care referrals

• Later referrals to hospice

• Twice the rate of hospital deaths

• More aggressive care at EOL

• Similarly high symptom burden

SO WHY IS THIS?

Disease Characteristics

• The lure of the cure

• More rapid trajectory to death in advanced disease

• Unpredictable and unique complications from therapy

• Ours is the only tumour site for which we are able to provide ORT once the organ is infiltrated with refractory cancer

• Unrealistic patient expectations at EOL (partly due to hx of prior successes)

Challenges within BC

• Long relationship with our patients, thus harder to involve another service at EOL – Hematology compared to oncology

– Hematologists compared to other transplanters

– We are not a referral transplant centre

• Our outpatient ward is an excellent resource – When EOL comes, difficult to wean patients

from CP6 (but fatiguing to continue to attend)

• Geographic constraints – Most patients return to small communities

which may not have any experience with palliation in hematological illnesses.

At Vancouver General..

• ….how are we addressing some of these

issues, from a palliative care doc’s

perspective?

– Dr. Yeomans

How do we identify patients who

would benefit from a palliative

approach? 1. Patient choice/need for supportive care

2. The surprise question: “Would you be surprised if this patient were to die in the next year?”

3. Sentinel events eg. The third admission to ICU for ventilation

4. Clinical indicators

Dr Bev Spring, Vancouver Home Hospice Program

Patients with malignant hematological

disorders treated on a palliative care unit:

prognostic impact of clinical factors.

• High LDH

• High Calcium

• High CRP

• Low Plts

• Low total protein

• Low Hgb

• Poor PS

• Need for opioids (pain or

dyspnea)

• Need for parenteral nutrition

• Need for transfusions

Multivariant analysis showed

shortened survival time in

1. Low albumin

2. Low plts

3. High LDH

4. Poor ECOG

5. Need for opioids

Ann Hematol. Feb 2014

What staff told us about

“Palliative Care” Staff perceptions

• Comfort Care

• Non curative

• Quality vs quantity

• Time specific for programs and services

• Symptom management

• Dignity

• Choices

• Respite

• Change of focus

• Elephant in the room=death

Patient perceptions • Dead in a week • Abandonment • The end • No more cure • Decreased treatment • Stopping treatment • End of connection/

relation with heme team • Last stop/a place to die • Positive informed choice • Team pulling away

Credit E. Beddard-Huber

Characteristics of palliation with

different illness trajectories

Solid organ cancers

• Look and feel unwell

• Require less interventions

from oncologists

• Connection with community

care givers seen as helpful

• Palliative interventions can

often be done in the

community

• Performance status is a

good predictor of prognosis

Hematological malignancies

• Relatively asymptomatic, good QOL

• Require increasing medical support (transfusions, antibiotics, hydroxyurea)

• Connection with community seen as not necessary

• Palliation of symptoms e.g infections, bleeding requires rapid response

• Performance status is not a predictor

Transitional Milestones… Triggers identified by LBMT staff

Transitions

Early

At diagnosis

Induction

Admission Pre/Post Transplant

Admission to CP6

Disease

progression on

Hydroxyurea

Transitions Transitions

Relapse

Options for Clinical Trials

Symptom Burden

Transitions Transitions

Death and

bereavement

Patient Journey

McGregor and Porterfield 2009 Beddard-Huber 2015

Diagnosis Best Supportive Care Progression Terminal Phase

And now for some

practical tips…

How do Our Patients Die?

• Consequences of Bone Marrow Failure – Profound and prolonged thrombocytopenia –

bleeding

– Profound and prolonged neutropenia – sepsis

• Hyperleukocytosis/Leukostasis – Respiratory failure

– Intracranial thrombosis/bleeding

– Acute kidney injury – hyperkalemia, volume O/L

• If Post Allogeneic Transplant – Acute or chronic GVHD

– Unusual infections

Practical Tips: Palliating

Hematology Patients

• Reduce high WBC (“Blast”) Count with Hydroxyurea

– inhibits ribonucleotide reductase -> -> inhibit DNA synthesis and cause cell death

– Used mainly in myeloid disease (ie AML), sometimes in lymphoid diseases like ALL (prednisone, mercaptopurine)

– Well tolerated – can cause GI upset, skin ulcers, myelosuppression

– Who is not a good Hydrea candidate:

• Those already requiring very frequent transfusions

• Inability to swallow (eg gingival infiltration)

• Too fatigued to come for frequent B/W monitoring


Hematology Patients

• Bleeding – Prophylactic platelet transfusions (if appropriate) for

platelets <10

– Higher threshold if problematic bleeding (eg oral, epistaxis, prior intracranial etc)

– For symptoms even if B/W has ceased

– Tranexamic acid

• blocks dissolution of fibrin clots

• helpful if bleeding is from mucus membranes (oral, epistaxis, GI tract, menorrhagia etc). Not for urethral bleeding -> renal outflow obstruction

• Can be oral, IV, or mouthwash


Hematology Patients

• Red Cell Transfusions – Irradiation - no longer applies (same with CMV seronegative

IF they were receiving that previously)

– Generally hgb of 80g/L or 90 g/L as transfusion threshold (but really for symptoms), consider stopping when symptom benefit lost

– The crossmatch: MUST to be done at the same institution where the transfusion will take place, valid for 72 hours, thus a red cell transfusion is generally a minimum of 2 visits

• Fever and Infection – Neutropenic fever – IV antibiotics (if appropriate), and

cultures, step-down to PO.

– Persistent fever despite broad spectrum Abx and negative cultures: Consider Pulmonary Aspergillus, Central Line infection or Disease-Related fever

The future

• Integrate the different aspects of a

palliative approach to care within the

illness trajectory

• More academic approach to the study of

EOL care in the hematologic malignancy

population

• Facilitating transfusions outside of the

hospital setting

Conclusions:

• We need to consider that the traditional

palliative approach to care may need to

be modified for this patient population

• What is considered best quality EOL

care?

– Still an open question

Questions?

Documents

“Palliating the Leukemia/BMT Patient: Challenges and Tips”med-fom-fpit.sites.olt.ubc.ca/files/2015/12/3.-Drs-Rodrigo-and-Yeom… · Judith Rodrigo MD FRCPC Wendy Yeomans MD MCFP