This article is more than 5 years old. Information may no longer be current.
Inpatient palliative care may improve quality of life following HSCT
Click Here to Manage Email Alerts
Inpatient palliative care improved quality of life among hematopoietic stem cell transplant recipients, according to a nonblinded randomized clinical trial published in JAMA.
The physical and psychological demands of patients hospitalized for HSCT often lead to a decline in quality of life and mood and an increase in symptom burden during 3- to 4-week hospital stays.
“As an oncologist, I have watched patients with blood cancers undergo very intensive therapies and stem cell transplantation and experience substantial physical and psychological symptoms during their treatment,” Areej R. El-Jawahri, MD, director of the Bone Marrow Transplant Survivorship Program at Massachusetts General Hospital Cancer Center, told HemOnc Today. “Many clinicians believed that these symptoms are just a natural part of the transplant process and are not modifiable. Palliative care has expertise in complex symptom management and can provide an extra layer of support to help patients and caregivers undergo such intensive therapy.
“Therefore, we wanted to ask the question whether palliative care can help modify the transplant experience for patients with blood cancer and reduce their physical and psychological symptoms and improve their outcomes,” El-Jawahri added.
El-Jawahri and colleagues assessed the effect of inpatient palliative care on transplant recipients and their caregivers compared with standard care procedures.
The analysis included 160 adults (mean age, 57.1 years; 86.9% white; 56.9% women) undergoing HSCT at Massachusetts General Hospital from August 2014 to January 2016.
Eighty-one patients were assigned palliative care visits — which focused on management of physical and psychological symptoms — at least twice a week during their hospitalization. The remaining 79 patients were assigned to standard transplant care but could be seen by palliative care clinicians on request. Two of those patients received a palliative care consultation.
In addition, researchers assessed quality of life of caregivers at baseline and at 2 weeks after transplantation.
Patients completed the Functional Assessment of Cancer Therapy–Bone Marrow Transplant, which includes physical, functional, emotional, social well-being and bone marrow transplant–specific subscales.
Change in patient quality of life from baseline to week 2 served as the primary outcome measure. Secondary endpoints included patient-assessed changes in mood, fatigue and symptom burden from baseline to 2 weeks and 3 months, as well as caregivers’ quality-of-life assessments and mood at baseline and 2 weeks.
Follow-up was completed in May 2016.
El-Jawahri and colleagues observed patients with palliative intervention reported less of a decrease in quality of life than those who received standard treatment (–14.72 vs. –21.54; P = .045) 2 weeks after hospitalization. Patients who received palliative intervention also reported less of an increase in depression (2.43 vs. 3.92; P = .02); lower anxiety (–0.8 vs. 1.12; P < .001); and less of an increase in symptom burden (17.35 vs. 23.14; P = 0.3). Changes in fatigue were not statistically significant (–10.3 vs. -13.65).
At 3 months, patients who received palliative intervention reported higher quality of life and less depression. However, there were no significant differences in anxiety, fatigue or symptom burden.
“The most interesting and surprising finding for us is that we saw a sustained effect of the inpatient palliative care intervention on patient outcomes,” El-Jawahri said. “Specifically, patients receiving the palliative care intervention experienced improvement in their quality of life and reduction in their depression and post-traumatic stress symptoms 3 months after transplant. This suggests that modifying patients' experience during hospitalization for stem cell transplantation may have longer-term effects in terms of both quality of life and psychological distress. ... Patients who are experiencing high symptoms may benefit from asking for a palliative care clinician involved to help address their supportive care needs during transplant.”
Caregivers of intervention patients reported no significant difference in quality of life or anxiety after 2 weeks, but reported less of an increase in depression (0.25 vs. 1.8, P = .03).
Researchers noted their study was limited to one tertiary care site and the patient population lacked racial and ethnic diversity. They also noted the patients could not be blinded to the intervention, which may have introduced bias.
“It is important to emphasize that this is the first study demonstrating the role of palliative care in helping patients with blood cancers receiving curative therapy and their caregivers,” El-Jawahri said. “This is an example of how palliative care can enhance the quality of life and care of patients throughout their illness trajectory regardless of their prognosis.
“Palliative care should not be thought of as simply end-of-life care,” she added. “It is care that can enhance the quality of life and reduce symptom burden of patients living with a serious illness and those receiving curative therapy with stem cell transplantation.”
In an accompanying editorial published in JAMA, Preeti N. Malani, MD, MSJ, of the division of infectious diseases in the department of internal medicine at University of Michigan Health System, and Eric Widera, MD, of the division of geriatrics in the department of internal medicine at University of California, pointed out that palliative care remains a dynamic and evolving field.
“In particular, the results [of El-Jawahri and colleagues’ study] provide additional evidence that palliative care should not be restricted to the end of life,” Malani and Widera wrote. “In contrast, many individuals with potentially curable disease could benefit from the integration of specialized palliative care teams into usual clinical care.
“The results also suggest that simply having palliative care consultation available is not sufficient; only two individuals in the control group received formal consultation despite a protocol that allowed patients, caregivers or transplant clinicians to request palliative care involvement,” they added. “The integration of specialized palliative care teams into usual clinical care should be adopted as part of an updated standard of care, similar to the routine involvement of pharmacy, nutrition, and social work.”– by Chuck Gormley
For more information:
Areej R. El-Jawahri , MD, can be reached at Department of Hematology Oncology-Bone Marrow Transplant Program, 55 Fruit St., Cox 120, Boston, MA 02114; email: ael-jawahri@partners.org.
Disclosure: El-Jawahri reported funding from the National Palliative Care Research Foundation. Please see the full study for a list of all other researchers’ relevant financial disclosures. Widera is a board member of the American Academy of Hospice and Palliative Care Medicine. Malani reports no relevant financial disclosures.
Click Here to Manage Email Alerts