Clinical course and end-of-life care in patients who have died after allogeneic stem cell transplantation

Busemann, Christoph; Jülich, Andreas; Buchhold, Britta; Schmidt, Vanessa; Schneidewind, Laila; Pink, Daniel; Schmidt, Christian A.; Neumann, Thomas; Krüger, William

doi:10.1007/s00432-017-2446-y

Cited by 8 publications

(9 citation statements)

References 28 publications

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“…Importantly, we have identified many characteristics associated with high quality end-of-life care, including documented goals of care discussion and/or advanced care planning (96%); no chemotherapy in the last 14 days of life (93%); a palliative care consultation after relapse (32%); and hospice enrollment (40%) with a median hospice length of stay of 9 days. Our results compare favorably with aforementioned findings on end-of-life care in older AML patients in which only 23% patients enrolled in hospice (13), and almost 19% patients received chemotherapy in the last 14 days of life (14), and with reports on palliative care provision for these patients at the end-of-life (21–23). We do note, however, that our hospitalization/ICU admission rates at the end-of-life remains high at 84% and 33% respectively, similar to 89% and 36% respectively from a previous study (13).…”

Section: Discussionsupporting

confidence: 89%

“…We demonstrate here a high rate of primary palliative care delivery by transplant/leukemia physicians and a high percentage of patients with quality end-of-life care indicators, while the impact of subspecialty palliative care service in this patient population remains to be determined. Considering these patients’ poor prognosis and high symptom burden (22,23), early involvement of subspecialty palliative care service and ongoing collaboration with transplant/leukemia physicians may warrant prospective investigation.…”

Section: Discussionmentioning

confidence: 99%

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End-of-life care for older AML patients relapsing after allogeneic stem cell transplant at a dedicated cancer center

Lin

Elko

Perales

et al. 2018

Bone Marrow Transplant

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Older patients with acute myelogenous leukemia (AML) are at increased risk for mortality and morbidity. While allogeneic stem cell transplantation may provide cure in some patients, many still relapse after transplant and are then left with limited therapeutic options and poor survival. Moreover, the quality of the end-of-life care for these patients has not been previously reported. We describe here the end-of-life experience of a cohort of 72 older patients with AML who relapsed after first allogeneic stem cell transplant at our dedicated cancer center. Despite a median overall survival of only 4 months, we find a high level of primary palliative care delivered by transplant/leukemia physicians through goals of care discussions and/or advanced care planning and provide evidence for high-quality end-of-life care outcomes, often with concurrent disease-directed therapy. Our results compare favorably with end-of-life care outcomes reported for older AML patients, including those who did not undergo transplant. Given the poor prognosis and unique underlying vulnerabilities in this high-risk patient population, incorporating timely advanced care planning and palliative care delivery while exploring available salvage options may further improve end-of-life care outcomes.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

End-of-life care for older AML patients relapsing after allogeneic stem cell transplant at a dedicated cancer center

Lin

Elko

Perales

et al. 2018

Bone Marrow Transplant

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“…predictor of worse physical and mental health status. Distress was significantly lower than healthy population values, and clinically meaningful: 73 (42.7%) subjects reported high levels of symptoms distress (>15), with a mean number of prevalent symptoms ranging across time from 12 (SD ± 3) to 14 (SD ± 4) symptoms (mean number of symptoms across the cohort: 8 to 10) Busemann 2017 [ 29 ], Germany Retrospective chart review 123 patients who died after allo-SCT Somatic, psychic, and Spiritual needs • About 50% of patients did not live more than 5 months. Two-thirds died within 14 months after SCT.…”

Section: Introductionmentioning

confidence: 99%

What is known about palliative care in adult patients with allogeneic stem cell transplantation (allo-SCT)?

et al. 2021

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Patients undergoing allogeneic stem cell transplantation (allo-SCT) are given a real chance of cure, but at the same time are confronted with a considerable risk of mortality and of severe long-term impediments. This narrative, non-systematic literature review aims to describe the supportive and palliative care needs of allo-SCT recipients, including long-term survivors or those relapsing or dying after transplantation. It also evaluates the feasibility and effectivity of integrating palliative care early in transplant procedures. In this appraisal of available literature, the main findings relate to symptoms like fatigue and psychological distress, which appear to be very common in the whole allo-SCT trajectory and might even persist many years post-transplantation. Chronic GvHD has a major negative impact on quality of life. Overall, there is a paucity of research on further issues in the context of allo-SCT, like the distress related to the frequently unpredictable post-transplant trajectory and prognosis, as well as the end-of-life phase. First randomized controlled results support the effectiveness of early integration of specialized palliative care expertise into transplant algorithms. Barriers to this implementation are discussed.

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“…Rationales for this EOL pattern of care have been proposed, including the unpredictable pattern of clinical decline in patients with hematologic malignancies, clinicians' bias toward offering all possible treatments for these patients, and the small but finite possibility of cure for select patients [17]. Studies have similarly demonstrated that adults undergoing allogeneic HCT for hematologic malignancies use high levels of healthcare resources at EOL [18][19][20][21][22]. However, despite the exceedingly high risk of mortality in AL/MDS patients who relapse after allogeneic HCT, little data exist specifically examining the intensity of healthcare utilization broadly and at the EOL in this patient population, with the few existing studies reporting qualitative or limited data on small patient samples [23,24].…”

Section: Introductionmentioning

confidence: 99%

Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation

Langston

Sundaram

Periyakoil

et al. 2019

Biology of Blood and Marrow Transplantation

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Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodysplastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, inpatient healthcare utilization of this population is unknown. Here we describe survival, intensity of healthcare utilization, and characteristics associated with high resource use at the end of life (EOL). Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We compared the distribution of demographic and clinical characteristics of patients as well as healthcare utilization over 2 years postrelapse and at EOL by postrelapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity by summing the presence of any of the following criteria: death in the hospital, use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense healthcare use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, postrelapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. One hundred fifty-four patients were included; median age at relapse was 56 years (interquartile range [IQR], 39 to 63), 55% were men, 79% had AL, and median time from HCT to relapse was 6 months (IQR, 3 to 10). After relapse, 28% received supportive care only, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion, second HCT, or donor lymphocyte infusion plus second HCT). With the exception of time until relapse and Karnofsky Performance Status, baseline characteristics (gender, age, race, graft-versus-host disease, year of treatment) did not significantly differ by postrelapse treatment group. One hundred thirty-six patients (88%) died within 2 years of relapse; survival differed significantly by postrelapse treatment group, with those receiving disease-directed treatment showing lower risk of death. Healthcare use in AL/MDS patients after post-HCT relapse was high overall, with 44% visiting the emergency department at least once (22% at least 2 times), 93% hospitalized (55% at least 2 times, 16% at least 5 times), and 38% using the intensive care unit (median length of stay 5, days; IQR, 3 to 10). Use was high even among those receiving only supportive care. For those patients who died, the mean intensity score for EOL healthcare use was 1.8 (standard deviation, 1.8). Most patients (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, an increase in age (estimate-.03 (95% CI,-.06 to-.003) and having AL versus MDS were significantly associa...

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Clinical course and end-of-life care in patients who have died after allogeneic stem cell transplantation

Cited by 8 publications

References 28 publications

End-of-life care for older AML patients relapsing after allogeneic stem cell transplant at a dedicated cancer center

End-of-life care for older AML patients relapsing after allogeneic stem cell transplant at a dedicated cancer center

What is known about palliative care in adult patients with allogeneic stem cell transplantation (allo-SCT)?

Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation

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