Perspectives on Advance Care Planning for Patients with Hematologic Malignancy: An International Clinician Questionnaire

Abstract

Background: Critical illness is common in hematological malignancy (HM) patients. Advance care planning (ACP) can allow these patients to express their care preferences prior to life-threatening illnesses. The objective of this study was to evaluate physicians' perspectives surrounding ACP in HM patients. Methods:We administered a survey to intensivists and hematologic oncologists who care for patients with HM across Canada and the United Kingdom. Potential respondents were identified from institutions that have a hematologic oncology program. The survey was disseminated electronically.Results: 111 physicians completed the survey with a response rate of 19% (39% across those who opened the email); 52% of respondents were intensivists and 48% hematologic oncologists. 15.5% of physicians reported that ACP happens routinely at their institution, while 8.3% of physicians stated that code status is routinely discussed. ACP discussions were most commonly reported at the onset of critical illness (84.3% of respondents), during disease recurrence (52.9% of respondents), or during transition to a strictly palliative approach (54.9% of respondents). Commonly cited barriers to ACP centred on physicians' concern about the reaction of the patient or family. Conclusion:This study emphasizes the need for earlier and more frequent ACP discussions in this high-risk population with a variety of barriers identified.

Advance care planning in oncology: a scoping review and some recommendations

“…Patients', their relatives', and HCPs' willingness to communicate about ACP theoretically depends on their beliefs regarding the expected outcomes of that communication (i.e., outcome expectancy beliefs). Three recent studies highlighted negative outcome expectancy beliefs regarding ACP among HCPs [35] and patients with cancer [25,30]. HCPs reported that ACP discussions may overwhelm and upset patients and relatives, inducing unnecessary stress or unleashing uncontrollable emotions, with worrisome psychological outcomes [35].…”

“…Three recent studies highlighted negative outcome expectancy beliefs regarding ACP among HCPs [35] and patients with cancer [25,30]. HCPs reported that ACP discussions may overwhelm and upset patients and relatives, inducing unnecessary stress or unleashing uncontrollable emotions, with worrisome psychological outcomes [35]. Hispanic and Latino patients in the US reported that the wish to safeguard their families from confronting death, and thereby distressing them, was a barrier to engaging in ACP discussions [26 ].…”

“…Thirty-eight studies [15–52] and three reviews were identified [6 ▪ ,8 ▪▪ ,13 ▪▪ ]. Studies were heterogeneous in terms of cancer care contexts, population size and characteristics, research designs, and assessment methods (Table 1).…”

“…Factors associated with ACP communication were allocated to five categories (based on ACP uptake [13 ▪▪ ] and communication in healthcare [14] models): ACP uptake-predisposing factors and barriers [15–23], ACP uptake-enabling factors and barriers [15,18,24,25,26 ▪ ,27–29], perceived need for ACP communication and barriers [15], ACP communication–enabling factors and barriers [17,18,23,25,26 ▪ ,30–38], and willingness to communicate about ACP [23,30–32]. Fourteen articles that were not included in these categories are reported in Table 1.…”

Acute Respiratory Distress Syndrome following Hematopoietic Stem Cell Transplantation: One More Piece in the Puzzle

“…It also identifies a high-risk cohort in which the risk of ARDS can be discussed together with other risk factors for transplant-related morbidity and mortality at the time of initial consultation. This may also potentially inform advanced care planning discussions ( 13 ). The authors should be commended for putting together one of the largest contemporary cohorts of patients with HCT and describing early factors associated with the subsequent development of ARDS.…”