Improving End of Life Care for Hematology-Oncology Patients within the Rossy Cancer Network

Introduction: The clinical course of hematology-oncology patients differs from patients with solid malignancies as these patients are more likely to be admitted to receive life sustaining measures near end of life (EOL). In a survey conducted among hematologist-oncologists, EOL indicators validated for medical oncology patients and considered significant for hematology-oncology patients, included not being admitted to intensive care, intubated or receiving CPR within 30 days of death, not receiving chemotherapy within 14 days or a blood transfusion within 7 days of death, and dying outside of an acute care unit (Odejide et al., JCO 2016). To better understand EOL trajectories for patients with hematological malignancies, we conducted a retrospective chart review using the Rossy Cancer Network (RCN) registry of the McGill University hospitals, Montreal, Canada. The objectives were 1) to describe the demographics, trajectory and physician-established goals of therapy (GOT) (remission, slow progression, palliative) for patients from their final admission to hospital to death, 2) measure adherence during that period of time with regard to the six quality EOL indicators outlined above and 3) measure how palliative care (PC) involvement, level of intervention (LOI) discussions and physician GOT impacted performance on these indicators.

Methods: Using the RCN registry, we identified patients who died from hematological malignancies between April 2014 and March 2016 (n=749) at the four participating McGill hospitals. Inclusion criteria required that the patient have a hematological malignancy confirmed by pathology, be treated at a McGill University hospital, and that the cause of death be related directly to the malignancy or its treatment. We performed retrospective chart reviews to delineate patient trajectories. All ICU, hematology and PC consultations, LOI, progress notes, discharge summaries, pharmacy prescriptions and death forms needed to be available for the chart to be considered complete. Median duration of last hospitalization to LOI discussion, PC consultation and death was determined. In addition, performance on all six EOL indicators was measured and we assessed the impact of physician's GOT, PC involvement and early LOI discussion on these indicators. The chi-square test was used to compare categorical variables.

Results: Of the 749 patients assessed in the registry, 322 met all inclusion criteria. 427 were excluded: 215 did not meet inclusion criteria, 182 died outside of the established time window, 26 were duplicate entries and 4 of the charts were incomplete. The registry included 132 patients with lymphoma, 110 patients with leukemia, 53 patients with myeloma and 24 patients with myelodysplastic syndrome. The median number of days from admission to death was 15 (interquartile range (IQR) 6-36). The most common patient trajectory was a LOI discussion 9.5 days (IQR 4-22) and PC consultation 9 days (IQR 3.5-19.5) prior to death. For the whole cohort, 62% of patients had a consultation with PC prior to death and 34% of patients had a documented LOI prior to their last admission. The treating physician's GOT was to induce remission in 22%, to slow progression in 40% and to provide palliation in 37% of patients at the time of their last hospital admission. In addition, 17% of patients were administered chemotherapy less than 14 days prior to death, 20% were admitted to ICU, 14% were intubated and 5% received CPR less than 30 days prior to death, 18% received blood transfusion less than 7 days prior to death and 67% died in an acute care setting. EOL indicators significantly improved when stratified by physician GOT (p < 0.01, 6/6 indicators), a PC consult was completed (p < 0.001, 5/6 indicators), and a LOI discussion was held prior to admission (p < 0.02, 5/6 indicators).

Conclusions: In this study we demonstrate a relationship between LOI discussions, PC consults and physician established GOT on EOL quality indicators for patients with hematological malignancies. Our findings suggest that setting appropriate GOT and having timely LOI discussions and early PC involvement may improve EOL experiences for patients. We plan to implement prospective quality improvement initiatives aimed at these factors and measure the performance on these EOL indicators. Ultimately, our goal is to improve the quality of end of life care for patients.