Expanding Palliative Care

Harvard Medical School| Mon Nov 28 10:02:19 EST 2016
Expanding Palliative Care

Integrating palliative care into the treatment of patients undergoing hematopoietic stem cell transplantation (HCT)—commonly known as bone marrow transplantation—for such cancers as leukemia and lymphoma can improve their quality of life, relieve symptoms associated with the procedure and reduce depression and anxiety.

These benefits were felt not only during the three- to four-week hospitalization required for the procedure but for several months following.

 Harvard Medical School researchers at Massachusetts General Hospital also report that caregivers of patients receiving palliative care experienced less depression and were better at coping with the stress associated with the illness of their family member or friend.

“Palliative care clinicians are increasingly asked to help care for patients with solid tumors but are rarely consulted for patients with hematologic malignancies, especially those receiving therapy designed to cure their disease,” said Areej El-Jawahri, HMS instructor in medicine at Mass General and lead author of the JAMA report.

Not just for end-of-life care

“The physical and psychological symptoms associated with HCT are sometimes regarded as expected and unavoidable, which—combined with the persistent misperception that equates palliative care with end-of-life care—has contributed to a lack of involvement of palliative care clinicians in the care of these patients,” El-Jawahri said.

After a patient with a hematologic cancer is admitted to the hospital for HCT, he or she receives high-dose chemotherapy and/or radiation therapy to eradicate diseased cells in the body. About one week into hospitalization, stem cell transplantation—an infusion of healthy blood-system stem cells—is conducted to begin repopulating the marrow.

In addition to symptoms caused by chemotherapy—including nausea, pain, vomiting, diarrhea, fatigue and insomnia—HCT recipients must stay in a protective environment to prevent infection, which limits their interactions with family members and friends.

Isolation

That isolation, along with the physical symptoms produced by the procedure itself, contributes to psychological symptoms of depression and anxiety. For some patients, the grueling process leads to post-traumatic stress disorder.

The JAMA study enrolled 160 patients who underwent HCT for a variety of hematologic malignancies at Mass General from August 2014 to January 2016. Participants were randomly assigned to receive either standard care or the palliative care intervention.

Within three days of their admission to the hospital, patients in the intervention group had an initial meeting with a palliative care clinician—a physician or advanced practice nurse, who continued to meet with them at least twice a week during their hospitalization.

At the meetings, which could be attended by a family member or a friend of the patient, clinicians first focused on establishing a rapport with patients and their caregivers. They addressed ways of managing the physical and psychological symptoms patients were experiencing and provided support and strategies for coping with distress. Patients received an average of eight palliative care visits during their hospitalizations, which lasted on average 20 days.

At the outset of the study and two weeks into the process, a time when patients’ blood levels are at their lowest and symptoms tend to be at their worst, patients in both groups and participating caregivers completed questionnaires assessing their mood and quality of life. Patients completed additional questionnaires regarding symptoms of their illness and those associated with the procedure. Three months after transplantation, patients completed additional assessments.

Quality of life

The primary question the study was designed to investigate was whether receiving palliative care reduced the expected decline in quality of life experienced by patients at two weeks. The results indicated significantly better quality-of-life scores for those receiving the palliative care intervention than for the usual treatment group, both at the two-week and the three-month assessments.

Patients receiving the palliative care intervention also reported lower levels of depression, anxiety and symptoms at two weeks. They continued to experience less depression, better quality of life and fewer post-traumatic stress symptoms than the control group at three months.

Family-member or friend caregivers attended 42 percent of the palliative care sessions; at the two-week assessment caregivers in the intervention group were found to have fewer depression symptoms and better coping skills when compared with caregivers in the control group.

Caregivers’ role

“Caregivers play a crucial role in supporting patients during the transplant process, and they are substantially impacted as they watch their loved ones struggle with side effects that can be emotionally challenging,” explained El-Jawahri, who is also director of the Bone Marrow Transplant Survivorship Program in the Mass General Cancer Center.

El-Jawahri and her colleagues noted that additional, larger studies are needed to assess impacts on caregivers more completely, to replicate patient results at centers with more diverse patient populations, to assess the inclusion of more complete palliative care teams, to collect cost data and to adapt the palliative care intervention to assist patients receiving other potentially curative treatment for hematologic or other cancers.

Jennifer Temel, senior author of the JAMA paper and HMS associate professor of medicine at Mass General, added, “An important aspect of this study is its extension of the benefits of palliative care beyond patients with advanced solid tumors to those receiving curative therapy for hematologic malignancies. Our results highlight how palliative care can be beneficial for patients with cancer regardless of their prognosis.”

The study was supported by funds from the National Palliative Care Research Foundation and by National Institutes of Health grant K24 CA181253.

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