FEATURE
had a better quality of life (QOL)
compared with those who received
standard care, along with less depression and a longer median survival
– despite receiving aggressive EOL
care.
In a second study, early palliative care in patients with advanced
cancer led to improvements in a
variety of outcomes, such as QOL
and satisfaction with care compared
with standard care.5
Although these studies were done
in solid tumor patients, the lessons
still apply, Dr. LeBlanc said. “Everyone tends to assume that palliative
care is what you do when you can’t
do more treatment, but introducing
palliative care early has two main
benefits: It can used along with, not
instead of, active cancer treatment
and it can help establish a relationship
between the patient and the palliativecare specialists.” The transition to
EOL care, then, seems less jarring.”
Providing a Cure at Any
Cost?
The unique circumstances of treating hematologic malignancies also
presents challenges to better integrating palliative care in this setting.
In the last 30 days of life, patients with hematologic malignancies are likely to undergo “aggressive” care including admission to
intensive care, chemotherapy, and
targeted therapy, compared with patients with solid tumors, according
to a 2014 study, indicating “a relative lack of palliative care involvement in hematologic patients.”6
That finding didn’t come as a
surprise to Dr. Back. “I used to
work with patients with end-stage
lymphoma who needed platelet
transfusions,” he said. “I would tell
them that they should receive platelet transfusions until they were too
weak to come in and then get them
as an outpatient, because, at that
point, this treatment is not going to
help them and they would be wasting too much energy.”
However, that’s not a common
approach, he added. “Physicians
would typically have the patient
continue to come to the hospital for
platelet transfusions. The risk there
is that the patient ends up dying in
the hospital, which may not have
been what the patient wanted.”
That drive to cure, despite what
the patient may want for his or
her life, can stymie open communication between physicians and
patients about palliative care. It is an
area where hematologists may want
to consider conversing with patients
before moving forward.
Ms. Long suggested that physi-
ASHClinicalNews.org
”We need to
figure out
when the
palliative-care
specialist is
most helpful
and how we
can maximize
the benefit of
adding that
person to the
team.”
—THOMAS LEBLANC, MD
cians kick off the conversation by
establishing the goals of care. “Ask
the patient what he or she hopes for,
and then ask what he or she worries
about. The answers can give you
a better perspective on what the
expectations are.”
She also cautioned that patients
may have to hear the same information more than once. “More often
than not, patients are hoping for a
cure, regardless of what the doctor
or the nurse has told them about the
prognosis,” she said. “If they express
the belief that they are going to be
the one person who can beat the
disease, that clues me in as a nurse
educator that I need to circle back
and reiterate previous information.”
Initiating the conversation can,
understandably, be difficult for hematologists because, Dr. Back noted,
many hematologists may fear that
anything short of curative intent is
akin to abandonment.7
“Hematologic malignancy specialists often work with patients for years
from diagnosis, through treatment,
through recurrence, before and after
transplant,” he said. “They have a
deep commitment to these patients,
and when they are unclear as to what
palliative care practices may be they
may want to revert to their typical
approach – the most aggressive treatment a patient can handle.”
Dr. Brandoff added that communication between the physician and
patient cannot be a one-way street.
“Even the most confident patient
will be startled if there is a marked
change in tone, content, and style,
in terms of their interaction with
their doctor,” he said. “Take the time
to step back and check in.”
However, because the clinical
status of a patient with a hematologic
malignancy can turn on a dime, this
time might not be possible. So, Dr.
Brandoff recommends investing in
palliative care discussions along the
patient’s treatment course; then, when
treatment changes need to happen
quickly, “you can tap into that investment you developed over time.”
Keeping the Conversation
Going
Despit