Palliative Care Utilization, Transfusion Burden and Symptoms for Patients with Multiple Myeloma at the End of Life

Introduction:

Despite dramatic treatment advances , multiple myeloma (MM) remains a significant source of morbidity and mortality with 13,000 deaths expected annually in the United States. We characterized patterns of mortality, palliative care involvement, and disease course at the end of life for patients with MM over the last decade.

Methods:

We assessed all consecutive deceased patients with a diagnosis of MM who received health care at a single health care institution from January 2010 to December 2020. Institutional Review Board approval was obtained prior to data review. Descriptive statistics were employed, and chi square was used to compare categorical variables.

Results:

A total of 456 patients were identified. Patient characteristics and outcomes are listed in Table 1.

In the year prior to death, the prevalence of depression was 45.8% (209 patients), whereas 75.4% of patients were on opiates as an outpatient (344 patients). The mean number of lines of treatment received from diagnosis to death was 3 (range 0-12). Two-hundred eleven (46.3%) patients required red blood cell transfusions in the year prior to death.

Palliative care physicians saw 207 (45.4%) patients, of which 97 (46.9%) were seen as outpatient (including those who saw both outpatient and inpatient), and 110 (53.1%) exclusively as an inpatient. The median time from first palliative care consultation to death was 10 days for inpatient palliative care (range 0-389 days), and 107 days for outpatient palliative care (range 2-2028 days). Only 42 (9.2%) patients saw palliative care ≥6 months prior to death.

Compared to those patients who did not see palliative care, those that saw palliative care ≥6 months prior to death were more likely to be female (61.9 versus 42.2%, p=0.05), younger (median age at diagnosis 66 versus 71, p=0.03), and have a longer survival (46 months versus 35 months, p=0.006) (Table 1 and Figure 1).

Amongst the patients for whom place of death was clearly reported (351, 77%), 117 patients (33.3%) died in the acute care setting, 110 (31.3%) died in a hospice facility, and 124 (35.3%) died at home. Outpatient palliative care consultation did not correlate with a statistically significant difference in deaths in an acute care setting (22/81, 27.2% seeing outpatient palliative care versus 57/174, 32.8% for those who did not, p=0.36), or in chemotherapy (any active treatment other than just steroids) utilization in last month of life (30.9% versus 29.7%, p=0.83).

Conclusion:

In our analysis of the entire trajectory of the MM patient experience from diagnosis to death, we found a substantial proportion of patients with MM report depression, need opiates for pain control, require blood transfusions and are repeatedly hospitalized in the year prior to their death. A fifth of all deaths occur within a year of diagnosis. With a median of three lines of therapy from diagnosis to death, patients may not live to experience therapies reserved for later lines of treatment. A minority of these patients see a palliative care physician during their treatment journey with the median time from palliative care consultation to death only a month. Palliative care referral at this health system is physician-initiated and not based on standard criteria, which may impact these findings. While there is no clear correlation that palliative care consultation impacted the rate of acute care deaths or decreased utilization of MM treatment in the last month of life, (two common but complicated proxies for quality of end-of-life care), further prospective research on optimal utilization of specialist palliative care is required.

Figure 1

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Figure 1

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