Code status transitions in patients with high-risk acute myeloid leukemia

Abstract

Patients with high-risk acute myeloid leukemia (AML) often experience intensive medical care at the end of life (EOL) including high rates of hospitalizations and intensive care unit admissions. Despite this, studies examining code status transitions are lacking. We conducted a mixed-methods study of 200 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014-2021. We defined high-risk AML as relapsed/refractory or diagnosis at age ≥60. We used consensus-driven medical record review to characterize code status transitions. At diagnosis, 86.0% (172/200) of patients were 'full code' (38.5% presumed, 47.5% confirmed) and 8.5% had restrictions on life-sustaining therapies. Overall, 57.0% of patients experienced a transition during the study period. Median time from last transition to death was 2 days (range 0-350). Most final transitions (71.1%) were to comfort measures near EOL; only 60.5% of patients participated in these last transitions. We identified three conversation types leading to transitions: informative conversations focusing on futility after clinical deterioration (51.0%); anticipatory conversations at the time of acute deterioration (32.2%); and pre-emptive conversations (15.6%) prior to deterioration. Younger age (B=0.04, P=0.002) and informative conversations (B=-2.79, P<0.001) were associated with shorter time from last transition to death. Over two-thirds of patients were "presumed full code" at diagnosis of high-risk AML, and most experienced code status transitions focused on futility of continuing life-sustaining therapies near EOL. These results suggest that goals-of-care discussions occur late in the illness course for patients with AML and warrant interventions to increase earlier discussions regarding EOL preferences.

Advancing Palliative Care Integration in Hematology: Building Upon Existing Evidence

“…Another study of 200 leukemia patients reported the median time from last code status transition to death was only two days. Thirty-two percent (32%) of those code status conversations occurred at the time of clinical deterioration and 39.5% Current Treatment Options in Oncology without the patient present or capable of making their own medical decisions [73]. Thus, there are significant opportunities for improvement in advance care planning and symptom management in acute leukemia care.…”

End of life in haematology: quality of life predictors – retrospective cohort study

“…Blood cancers can be aggressive and rapidly fatal; or, blood cancers may have a relapsing and remitting course for which multiple, effective lines of therapy are available, making it hard to determine prognosis 9 10. As a result, clinicians may be less willing to institute EOL care and timely level of intervention (LOI) discussions or consultation with palliative care (PC) 11–15…”