Advance care planning and end-of-life care for patients with hematologic malignancies who die after hematopoietic cell transplant

Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review

“…Included studies were conducted with populations predominantly composed of patients with stage III or IV cancer or patients who recently died from cancer. Cancer types included breast, 42 hematological, 35,33 gynecological, 1,34,48 lung or gastrointestinal, 39 and any type. 23,31,32,[36][37][38]40,41,43,45,46,48,51 Sample sizes ranged from 84 to 2752 participants, with a median of 226 participants per study.…”

“…Eighteen studies assessed relationships between EOL discussions and health-care utilization near death 1,23,[32][33][34][35][38][39][40][41][42][43][45][46][47][48]51 and 6 studies assessed place of death. 1,33,35,42,47,51 In addition, 6 studies incorporated elements of time in their assessment of EOL discussions, generally referring to these discussions as early (31þ days before death) or late (within 30 days of death), with later conversations typically occurring in inpatient settings. 1,23,31,41,48…”

“…34,41,43,48 The 6 studies that assessed place of death found associations between EOL discussion and death outside a hospital but generally used mixed definitions of ACP as the comparator. 1,35,33,42,47,51 Eckhert and colleagues (n ¼ 163), who broadly defined an EOL discussion as an outpatient GOC discussion, AD, POLST, or DNR/DNI more than 30 days before death, found patients with ACP were more likely to die in hospice than the ICU (P ¼ .001) or in a non-ICU acute care setting (P ¼ .004). 35 Conceptualizing EOL discussion to also include ACP, GOC, and discussion proxies such as POLSTs and ADs, Zakhour and colleagues (n ¼ 136) found patients who had a discussion inpatient had much higher odds of dying in the hospital than patients who had a discussion outpatient (34% vs 0%, OR ¼ 20.5, 95% confidence interval [CI]: 1.19-352.6, P ¼ .04), providing context to possible relationships between discussion location and place of death.…”

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

“…Our findings beg the question of what may be done to temper the use of nonbeneficial and expensive healthcare services among patients with exceedingly high morbidity and short life expectancy. Although we did not find that advance care planning or palliative care consultation independently impacted EOL healthcare intensity, others have demonstrated a multitude of benefits associated with palliative care consultation and advance care planning both near the EOL and concurrent with disease-directed treatment in both solid tumor and hematologic malignancy patients [18,20,[33][34][35][36][37][38][39][40]. Various models have been proposed for integrating palliative care into the bone marrow transplant setting, particularly in pediatric populations [41].…”

“…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].…”