Trends in Health-Care Utilization at the End of Life Among Patients With Hematologic Malignancies in a Middle-Income Country: Challenges and Opportunities in Brazil

Abstract

Patients with hematologic malignancies (HMs) often receive poor-quality end-of-life care. This study aimed to identify trends in end-of-life care among patients with HM in Brazil. We conducted a retrospective cohort study (2015-2018) of patients who died with HM, using electronic medical records linked to health insurance databank, to evaluate outcomes consistent with health-care resource utilization at the end of life. Among 111 patients with HM, in the last 30 days of life, we found high rates of emergency department visits (67%, n = 75), intensive care unit admissions (56%, n = 62), acute renal replacement therapy (10%, n = 11), blood transfusions (45%, n = 50), and medical imaging utilization (59%, n = 66). Patients received an average of 13 days of inpatient care and the majority of them died in the hospital (53%, n = 58). We also found that almost 40% of patients (38%, n = 42) used chemotherapy in the last 14 days of life. These patients were more likely to be male (64% vs 22%; P < .001), to receive blood transfusions (57% vs 38%; P = .05), and to die in the hospital (76% vs 39%; P = .009) than patients who did not use chemotherapy in the last 14 days of life. This study suggests that patients with HM have high rates of health-care utilization at the end of life in Brazil. Patients who used chemotherapy in the last 14 days of life were more likely to receive blood transfusions and to die in the hospital.

A qualitative evidence synthesis of healthcare professionals’ experiences and views of palliative care for patients with a haematological malignancy

“…Bleeding complications are common at EOL in patients with haematology malignancies (Brück et al, 2012), resulting in significant transfusion requirements for haematology patients at EOL in both hospital and hospice settings in the last week of life (Brück et al, 2012;Cheng et al, 2015). Transfusion support is useful in improving symptoms of dyspnoea, fatigue and bleeding (Soares et al, 2019). However,…”

“…Findings elsewhere report the potential for cure for many blood cancers at an advanced stage, unlike most solid cancers which are incurable at an advanced stage (stage IV) (Odejide et al., 2016). Moreover, intensive medical care often continues for these patients even as they approach their final week of life (Brück et al., 2012; Cheng et al., 2015; Soares et al., 2019). Doctors’ therapeutic optimism is driven by their commitment to giving hope to their patients, which is at the heart of the doctor–patient relationship (Bressan, Iacoponi, Candido De Assis, & Shergill, 2017) and is one of the core elements of the “art of medicine” (Mambu, 2017).…”

“…Bleeding complications are common at EOL in patients with haematology malignancies (Brück et al., 2012), resulting in significant transfusion requirements for haematology patients at EOL in both hospital and hospice settings in the last week of life (Brück et al., 2012; Cheng et al., 2015). Transfusion support is useful in improving symptoms of dyspnoea, fatigue and bleeding (Soares et al., 2019). However, haematologists have expressed concern that hospice care could not meet the needs of patients because of their transfusion needs (McCaughan et al., 2018a; Odejide et al., 2014; Wright & Forbes, 2017).…”

“…However, it must be noted that the majority of patients in this latter study had a diagnosis of acute leukaemia. In another more recent study, patients who were given chemotherapy in the last 14 days of life were more likely to die in hospital (Soares, Gomes, & Japiassu, 2019). However, actively treating haematology patients in a context where there is no planning for end-of-end life causes distress for nurses (Grech, Depares, & Scerri, 2018).…”

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis

“…Compared to patients without metastases, patients with metastatic disease were more likely to use unscheduled care near the end of life 9,25 , and had a higher number of visits 9 . Cancer decedents who were currently receiving chemotherapy or radiotherapy were more likely to use unscheduled care than those who were not 28,31,32 . Patients receiving radiotherapy in their last month of life were more likely to present to ED 31 .…”