Increasing Palliative Care Team Involvement in Pediatric Hematopoietic Stem Cell Transplant Patients

Background/Objectives:

Palliative care facilitates communication, helps with physical and psychological symptom management, and assists in goals of care and advance care planning discussions. Multiple organizations including the World Health Organization, American Academy of Pediatrics and the American Society of Clinical Oncology encourage palliative care involvement. Palliative care involvement with hematopoietic stem cell transplant (HSCT) patients has been shown to be beneficial as HSCT is associated with a high degree of morbidity and possible mortality. We sought to increase the frequency of palliative care consultations for patients planning to undergo HSCT for targeted diagnoses.

The outcome measure was percentage of patients who underwent HSCT for a targeted diagnosis who had a Palliative Care Team (PaCT) consult. Baseline data revealed 48 patients underwent HSCT from July 2020 to July 2022, 25 of whom had a targeted diagnosis. PaCT met 12 of the 25 patients (48%). Our goal is to increase the number of PaCT consults for patients receiving HSCT for our targeted diagnoses from 48% to 75% by December 2023.

Methods:

Chart review was conducted for patients who underwent HSCT from July 2020 to July 2022. Demographics documented included reason for HSCT, if PaCT was consulted, date of transplant, date of PaCT consult and living status. A targeted diagnosis list was compiled based on which patients were felt to benefit most from palliative care involvement: relapsed or refractory leukemias and lymphomas, myelodysplastic syndrome, high risk acute myeloid leukemia and metabolic disorders, such as Hurler syndrome. The first plan-do-study-act (PDSA) cycle included discussion of the project at division meetings, posting flyers in the clinic provider workrooms, and education regarding palliative care and evidence of its involvement in HSCT patients. The second PDSA cycle implemented involved revision of the HSCT referral form to include the question “Is PaCT consulted.” If the provider answers “no,” further elaboration is requested.

Results: From 1/1/23 to 7/31/23 ten patients with a targeted diagnosis underwent HSCT. Five patients (50%) received a PaCT consult prior to HSCT.

Conclusions: Palliative care involvement in pediatric oncology is well established, but its role in HSCT patients continues to be explored. As HSCT patients receive more intense therapy, have frequent deaths in intensive care units and can have limited opportunity for end of life planning due to rapidly changing clinical courses, early integration of PaCT could allow for decreased symptom burden and distress for both patients and families. Future PDSA cycle interventions include adding PaCT consultation to the transplant evaluation order set in the electronic medical record and review of the comments on the completed HSCT referral forms to identify possible barriers in the PaCT consultation process.