Emergency Department–Initiated Palliative Care in Advanced Cancer

Grudzen, Corita; Richardson, Lynne D.; Johnson, Pauline N.; Hu, Ming; Wang, Binhuan; Ortiz, Joanna M.; Kistler, Emmett A.; Chen, Angela; Morrison, R. Sean

doi:10.1001/jamaoncol.2015.5252

Cited by 221 publications

(292 citation statements)

References 31 publications

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“…43–48 Specifically, although prior studies of early palliative care have shown improvement in patient-reported QOL, symptom burden, and mood, 43–48 the current trial demonstrates that early integrated palliative care ameliorates the risk of PTSD symptoms as well. These findings expand our knowledge about the potential benefits of palliative care for patients with hematologic malignancies and those receiving potentially curative therapy with HCT who were excluded from prior palliative care trials in oncology.…”

Section: Discussionmentioning

confidence: 74%

Effect of Inpatient Palliative Care During Hematopoietic Stem-Cell Transplant on Psychological Distress 6 Months After Transplant: Results of a Randomized Clinical Trial

El‐Jawahri

Traeger

Greer

et al. 2017

JCO

177

142

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Purpose Inpatient palliative care integrated with transplant care improves patients’ quality of life (QOL) and symptom burden during hematopoietic stem-cell transplant (HCT). We assessed patients’ mood, post-traumatic stress disorder (PTSD) symptoms, and QOL 6 months post-transplant. Methods We randomly assigned 160 patients with hematologic malignancies who underwent autologous or allogeneic HCT to inpatient palliative care integrated with transplant care (n = 81) or transplant care alone (n = 79). At baseline and 6 months post-transplant, we assessed mood, PTSD symptoms, and QOL with the Hospital Anxiety and Depression Scale and Patient Health Questionnaire, PTSD checklist, and Functional Assessment of Cancer Therapy-Bone Marrow Transplant. To assess symptom burden during HCT, we used the Edmonton Symptom Assessment Scale. We used analysis of covariance while controlling for baseline values to examine intervention effects and conducted causal mediation analyses to examine whether symptom burden or mood during HCT mediated the effect of the intervention on 6-month outcomes. Results We enrolled 160 (86%) of 186 potentially eligible patients between August 2014 and January 2016. At 6 months post-transplant, intervention participants reported lower depression symptoms on the Hospital Anxiety and Depression Scale and Patient Health Questionnaire (adjusted mean difference, −1.21 [95% CI, −2.26 to −0.16; P = .024] and −1.63 [95% CI, −3.08 to −0.19; P = .027], respectively) and lower PTSD symptoms (adjusted mean difference, −4.02; 95% CI, −7.18 to −0.86; P = .013), but no difference in QOL or anxiety. Symptom burden and anxiety during HCT hospitalization partially mediated the effect of the intervention on depression and PTSD at 6 months post-transplant. Conclusion Inpatient palliative care integrated with transplant care leads to improvements in depression and PTSD symptoms at 6 months post-transplant. Reduction in symptom burden and anxiety during HCT partially accounts for the effect of the intervention on these outcomes.

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Section: Discussionmentioning

confidence: 74%

Effect of Inpatient Palliative Care During Hematopoietic Stem-Cell Transplant on Psychological Distress 6 Months After Transplant: Results of a Randomized Clinical Trial

El‐Jawahri

Traeger

Greer

et al. 2017

JCO

177

142

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“…Three of the eight studies (38%) showed a small significant effect [36][37][38] and four (50%) a non-significant effect in favour of specialist palliative care [30][31][32][33] regarding the study specific assessment tools for quality of life (table 3).…”

Section: Risk Of Biasmentioning

confidence: 99%

“…Grudzen et al 37 published the most current randomised controlled trial that we included. In this elaborate adequately powered trial (n=136), the authors included patients with cancer but initiated specialist palliative care consultation (intervention group) only for those patients who were referred to the emergency department (control was consultation on request of the emergency physicians).…”

Section: Total ( % Ci)mentioning

confidence: 99%

Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis

Gaertner

Siemens

Meerpohl

et al. 2017

BMJ

298

227

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Objective To assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness. Design Systematic review with meta-analysis. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and trial registers searched up to July 2016. Eligibility criteria for selecting studies Randomised controlled trials with adult inpatients or outpatients treated in hospital, hospice, or community settings with any advanced illness. Minimum requirements for specialist palliative care included the multiprofessional team approach. Two reviewers independently screened and extracted data, assessed the risk of bias (Cochrane risk of bias tool), and evaluated the quality of evidence (GRADE tool). Data synthesis Primary outcome was quality of life with Hedges’ g as standardised mean difference (SMD) and random effects model in meta-analysis. In addition, the pooled SMDs of the analyses of quality of life were re-expressed on the global health/QoL scale (item 29 and 30, respectively) of the European Organization for Research and Treatment of Cancer QLQ-C30 (0-100, high values=good quality of life, minimal clinically important difference 8.1). Results Of 3967 publications, 12 were included (10 randomised controlled trials with 2454 patients randomised, of whom 72% (n=1766) had cancer). In no trial was integration of specialist palliative care triggered according to patients’ needs as identified by screening. Overall, there was a small effect in favour of specialist palliative care (SMD 0.16, 95% confidence interval 0.01 to 0.31; QLQ-C30 global health/QoL 4.1, 0.3 to 8.2; n=1218, six trials). Sensitivity analysis showed an SMD of 0.57 (−0.02 to 1.15; global health/QoL 14.6, −0.5 to 29.4; n=1385, seven trials). The effect was marginally larger for patients with cancer (0.20, 0.01 to 0.38; global health/QoL 5.1, 0.3 to 9.7; n=828, five trials) and especially for those who received specialist palliative care early (0.33, 0.05 to 0.61, global health/QoL 8.5, 1.3 to 15.6; n=388, two trials). The results for pain and other secondary outcomes were inconclusive. Some methodological problems (such as lack of blinding) reduced the strength of the evidence. Conclusions Specialist palliative care was associated with a small effect on QoL and might have most pronounced effects for patients with cancer who received such care early. It could be most effective if it is provided early and if it identifies though screening those patients with unmet needs. Systematic review registration PROSPERO CRD42015020674.

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“…Palliative care integration early in the disease course can help to address these aggressive end-of-life interventions and improve patients’ quality of life in other advanced cancer settings(13-18), but the unpredictable nature of blood cancers and the general attitudes of some hematologic oncologists towards palliative care provide several barriers to increased access(7, 19-21). Despite these barriers, a trend towards increased palliative care referral has been observed(22), along with a renewed call to examine the intersection between palliative care and the quality of life of blood cancer patients(23, 24), especially amid initial evidence of feasibility and efficacy in subpopulations such as those undergoing stem cell transplantations(25).…”

Section: Introductionmentioning

confidence: 99%

Comparing the Palliative Care Needs of Patients With Hematologic and Solid Malignancies

Hochman

Wolf

et al. 2018

Journal of Pain and Symptom Management

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Context Hematologic cancer patients use palliative care services less frequently than their solid tumor counterparts. Prior work suggests these patients have a sizeable symptom burden, but comparisons between hematologic and solid tumor patients near the end of life are limited. Objectives To compare unmet symptom needs in a cohort of hematologic and solid tumor patients referred to specialty palliative care services. Methods Using a novel data registry of initial palliative care encounters, we performed a cross-sectional analysis of cancer patients receiving care across seventeen sites within the Global Palliative Care Quality Alliance. We compared clinically-significant symptoms (rated as 4 or greater in severity) between hematologic and solid tumor patients and performed multivariate logistic regression analyses examining the relationship between symptom burden and tumor type. Results We identified 1,235 cancer patients, 108 of which had hematologic malignancies. Pain, dyspnea, nausea, and anorexia burden was as high among patients with hematologic as those with solid malignancies. Blood cancer patients had higher rates of clinically-significant tiredness (51% vs. 42%; p=0.03) than solid tumor patients. Finally, blood cancer patients had greater odds of being tired (odds ratio, 2.19; CI 1.22-3.91) and drowsy (odds ratio, 1.81; CI 1.07-3.07) than solid tumor patients independent of age, gender, race, and performance status. Conclusions Hematologic and solid tumor patients both have significant symptom burden at time of referral to palliative care services. Blood cancer patients may have unique concerns warranting targeted attention, including substantial drowsiness and tiredness. Our findings suggest a need to optimize palliative care usage in the hematologic cancer population.

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Emergency Department–Initiated Palliative Care in Advanced Cancer

Abstract: clinicaltrials.gov Identifier: NCT01358110.

Cited by 221 publications

References 31 publications

Effect of Inpatient Palliative Care During Hematopoietic Stem-Cell Transplant on Psychological Distress 6 Months After Transplant: Results of a Randomized Clinical Trial

Effect of Inpatient Palliative Care During Hematopoietic Stem-Cell Transplant on Psychological Distress 6 Months After Transplant: Results of a Randomized Clinical Trial

Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis

Comparing the Palliative Care Needs of Patients With Hematologic and Solid Malignancies

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