medwireNews: A US research team has found that end-of-life care among individuals who undergo allogeneic hematopoietic stem cell transplantation (HSCT) can often be medically intense.
The rates of markers indicating the intensity of care – such as hospital death or intensive care unit (ICU) admission – were “much higher than those found in general oncology patients,” say the study authors.
They comment that “[t]hese findings delineate those undergoing allogeneic [HSCT] as a subset of patients for whom end-of-life care research is vitally important and can help guide resource allocation and end-of-life care conversations in this population.”
Emily Johnston (Stanford University, California, USA) and colleagues highlight that “[m]ost importantly, concordance (or lack thereof) between the intensity of end-of-life care and the patient’s wishes remains undetermined.”
And they continue: “Multi-institutional studies and studies of patients without advance directives are needed to understand what their end-of-life goals are, whether they are receiving goal-concordant care, whether this high-intensity end-of-life care is goal concordant or determined by factors such as timing of end-of-life conversations, how end-of-life wishes are enacted, and whathospital practices are regarding end-of-life care.”
The population-based analysis included 2135 Californians who died within 1 year of receiving inpatient allogeneic HSCT, 53% of whom underwent at least one medically intense intervention, while 57% had at least two such interventions. Death in hospital was the most common indicator of intensity, occurring in 83% of patients, followed by admission to an ICU, intubation, and hospitalization for the last 30 days of life in 49%, 45%, and 43% of patients, respectively.
The researchers report in the Journal of Clinical Oncology that age and the presence of comorbidities were significant predictors of hospital death and receipt of medically intense care. For instance, adolescents and middle-aged adults were more likely to die in hospital than older adults, with the odds of a hospital death significantly increased 3.9-fold in those aged 15–21 years, and 1.9-, 1.5-, and 1.5-fold in those aged 30–39, 40–49, and 50–59 years, respectively, compared with patients aged 60 years or older.
Similarly, individuals with comorbidities or complications during their HSCT admission were significantly more likely to receive medically intense care than those with no comorbidities, with odds ratios of 1.6 for those with one comorbidity and 2.5 for those with two or more.
By contrast, medically intense interventions were less likely in patients with a diagnosis of acute myeloid leukemia or myelodysplastic syndrome versus acute lymphoblastic leukemia, those who received HSCT during 2000–2004 versus 2010–2013, those who changed hospitals between HSCT and death, and patients receiving care in a rural versus an urban location.
And the same factors, with the exception of HSCT year and location, were similarly associated with two or more markers of intense end-of-life care.
Johnston et al note that further work is needed in this area, in particular whether the intensity markers traditionally used in the oncology setting are appropriate for patients undergoing HSCT.
By Catherine Booth
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