Elsevier

Leukemia Research

Volume 27, Issue 6, June 2003, Pages 481-488
Leukemia Research

The final phase in acute myeloid leukaemia (AML): A study on bleeding, infection and pain

https://doi.org/10.1016/S0145-2126(02)00262-XGet rights and content

Abstract

To increase the knowledge of the final phase of acute myeloid leukaemia (AML) a retrospective review of the medical and nursing records of 106 adult patients with AML who had died in 1995–1997 was made. A total of 27 patients were treated with curative intent at the time of death and 79 patients were prescribed palliative care. From the documentation, an evaluation of the frequency and severity of bleeding and pain episodes was made during their last week in life, and the occurrence of infection criteria was studied. Notations on bleeding were found in 44%, infection in 71% and pain in 76% of the patients. In 54% of the morphine administration days, no information on the effect of given morphine treatment was registered. To give AML patients in the final phase, the best possible treatment, skills in palliative medicine and palliative care are important.

Introduction

The young woman in the intensive care unit (ICU) is unable to communicate. She is sedated and intubated and the ventilator is working. The former bone marrow transplantation (BMT) did not give a permanent cure. She has a relapse of acute myeloid leukaemia (AML) and has been treated with an intensive reinduction chemotherapy regimen. In spite of the fact that the bone marrow is void of leukaemia cells and has started to produce normal cells, all efforts to save her life have failed. Vital organs have ceased to function. This is one of the most tragic scenarios a haematological caring team can witness.

The hope of a definite cure in younger persons with AML has increased through different kinds of stem cells transplantations and improvement of supporting care. If still alive 2 years after BMT, 89% of the patients can expect to be free from leukaemia [1]. However, the majority of the total AML population is over 65 years with a poor prognosis and of the total AML population no more than 20% can expect a definite cure, the rest will die from their disease [2].

To the physician and staff the final phase of AML is an emotionally, professionally and ethically challenging period of care. Specialist textbooks do not often contain helpful information on caring for patients dying from their disease [3]. Palliative medicine is now evolving as a new speciality to increase the knowledge of how patients in the final phase of their disease perceive their situation and how they should be cared for at the end-of-life to give the best quality of life for patient and family [4]. In a former article, a group of patients with AML was presented according to cause of death, place of death and type of care during the last week in life [5]. In this article, further details are given on this period of the disease. As the study is retrospective, the data findings are obtained from diverse documentation in the medical records and are not obtained from direct observations.

Section snippets

Aim

The aim of this article is to increase the knowledge of the final phase of AML and give a description of some of the clinical problems that complicated the last week in life for a group of AML patients. Bleeding, infection and pain are focused as they represent areas where medical decisions have to be taken, which are of vital importance for the subsequent clinical course.

Patient population

In 1995–1997, 106 adult patients with the diagnosis AML had been taken care of in five selected hospitals and had died. The hospitals belonged to a regional network in central Sweden, which consisted of one university department (UD) (24 patients), one medical centre hospital (MCH) (29 patients) and three county hospitals with haematological units (hospital 1–3) (18, 14, 21 patients). These hospitals have the equipment necessary to give induction treatment in AML, namely blood bank, intensive

Bleeding

In over half of the medical records no notation on occurrence of bleeding was found. A total of 63 episodes of open bleeding were noted in 47 from the106 patients (44%). Sixteen patients had two or three sources of bleeding. In ten patients, cerebral haemorrhage was registered as the cause of death, and in eight of these cases also open bleeding episodes were noted. In Table 1, a combination of all episodes of open bleeding regardless of type is presented. The same patient could have had

Quality of registration, documentation and interpretation of findings

All our findings are based on registrations in the medical records and are thus depending on the quality of these documentation notes. A comparison of the quality of documentation in the various caring institutions would be of great interest but was not possible to perform. Our own experience from practical care and our familiarity with the medical documentation was a valuable asset in the procedure of interpreting the notations. However, to estimate the severity and duration of pain from the

Infection

In 71% of the patients, criteria for infection was noted. All the six patients in CR were infected as well as 90% in the youngest age group. The frequency was higher in the curative group than in the palliative, and the frequency of infection was lowest in the oldest group (80+ years). This might be the result of a policy to withhold curative chemotherapy treatment in this group. Sixty-one percent of the patients in the age group 60–69 years had registrations of infection, of which three

Place of death and physicians attitudes

In our study 61% of the patients died at home district hospital, 25% far from home and 14% close to home [5]. In Sweden, a growing trend is that a patient, who knows that cure cannot be effectuated, wants to die at home [11]. Hinton showed that patients cared for in hospice for eight weeks before death increased their acceptance of their forthcoming death, and that this death was obvious to next of kin earlier than to the patient [12]. HBHC, if adequate, was found to be a good form for caring

Concluding remarks

From the documentation in the medical records, we found that many AML patients had pain during the last week in life and that the documentation of morphine treatment was insufficient. To the physician, who wants to relieve a patient’s pain, the registration of the effect of the treatment given is very important. Our findings indicate that the quality of this feedback registration needs to be improved. We also found that bleeding was common, but was mostly slight and of short duration and thus

Acknowledgements

This study was supported by grants from the Örebro County Research Committee, the Swedish Cancer Society, The Blood Cancer Society of Sweden and the Lions Fund for Cancer Research. We thank the doctors and staff at the hospitals involved for their kind co-operation. A.M. Stalfelt contributed to all aspects of this clinical study, including drafting, revising the manuscript and giving final approval. B. Hakan contributed to the design, concept, analysis, assembly of data and provided statistical

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