Hemorrhagic complications in patients with advanced hematological malignancies followed at home: an Italian experience

Abstract

Patients with advanced hematological malignancies may experience many troublesome hemorrhagic complications requiring hospitalisation during a palliative home care (HC) program. We report on the feasibility of the management of bleeding at home in patients with haematological malignancies admitted in a domiciliary HC program. The occurrence of a major hemorrhage episode (>1 WHO grade) was registered among 469 patients with hematological malignancies in the terminal phase of their disease followed at home. Number, sites, domiciliary treatment (local hemostatic measures, platelet units, hemostatic drugs, packed red blood cells) and outcome of hemorrhagic complications were evaluated. Out of 469 patients, 123 (26%) experienced a bleeding complication; the overall number of hemorrhagic episodes was 232 (49%) with a median number of 2 episodes per patient. Patients with a platelet count lower than 20 x 10(9)/L (P < 0.00005) or with a diagnosis of acute leukemia or in blast crisis of myeloprolypherative disorders (P < 0.00005) showed a significant higher incidence of hemorrhages than other patients. Resolution of bleeding at home was obtained in 206 (88%) of the 232 episodes; platelet units were transfused at home in 188 (81%) cases. Bleeding was the cause of hospitalisation in four cases. Death occurred in 447 of 469 patients: in 26 of them (6%), it was caused by bleeding complications (11 brain hemorrhage, 2 hematemesis, 3 hemoptysis and 10 melena). In this group of patients, bleeding was a relevant clinical problem However, by implementing a domiciliary palliative care program, home management of hemorrhages proved to be a safe and effective choice.

Preferred and actual place of death in haematological malignancy

“…For example, blood product transfusions and intravenous antibiotics are needed to manage complications, including bone marrow failure, anaemia, bleeding and sepsis, and pain may also be a significant problem. [34][35][36] The situation is complicated by factors such as the availability of multiple lines of treatment, even in the later disease stages, which may be given to manage symptoms rather than with curative or disease modifying intent. 28 29 In this context, chemotherapy may continue into the terminal phase, again complicating the transitions in care.…”

Transfusion in Palliative Cancer Patients: A Review of the Literature

“…This is an ever increasing and valuable intervention in PCPs, 5 especially in hematologic patients. 7,13 The use of Plt-T for a prophylactic purpose is not recommended and should be abandoned. However, its use to control significant clinical bleeding (when moderate to severe thrombocytopenia occurs) could be mandatory.…”

“…However, its use to control significant clinical bleeding (when moderate to severe thrombocytopenia occurs) could be mandatory. 7,13 Two theoretical clinical aspects of Plt-T can be considered obstacles when facilitating this procedure at home: 5 (1) the expected high frequency of transfusion-related reactions and (2) the short lifespan of platelets. Regarding the first, this circumstance has not been observed, 7,13,14 so the procedure cannot be ruled out just by considering this obstacle.…”

Caring for the terminally ill patient with hematologic malignancies

“…The problem of terminally ill thrombocytopenic patients has been addressed in this issue of Leukemia & Lymphoma by Cartoni and coworkers [8]. They report on a systematic approach that is multidisciplinary and focused on quality of life as well as cost containment.…”