Most initial discussions on goals of care between clinicians and patients with hematologic malignancies occur in the inpatient setting and close to death, according to results from a retrospective study published in Cancer. Researchers found, however, that when discussions were further from death and when they involved a hematologic oncologist, patients were less likely to experience intensive health care use near death and were more likely to enroll in hospice.
Typically, patients with hematologic malignancies experience high use of intensive medical care near the end of life, and rates of hospice use are low.
Researchers assessed 383 patients with hematologic malignancies from the Dana-Farber Cancer Institute’s Oncology Data Retrieval System. All patients died in 2014. Among the patients, 23.7% had myeloma, 37.1% had lymphoma, and 39.2% had leukemia or myelodysplastic syndromes.
Discussions on goals of care were documented for 65.3% of patients overall, with 33.2% of discussions occurring more than 30 days before death, 46.4% occurring with a hematologic oncologist, and 34.8% occurring in the outpatient setting. Furthermore, 81.2% included discussion on resuscitation status, 32.4% on hospice, and 4.0% on preferred place of death. In 81.2% of discussions, the patient participated in the discussion, and in 18.8% of discussions, a surrogate for the patient participated in the discussion.
Results from multivariate analyses indicated that having the initial discussion in the outpatient setting (odds ratio [OR], 0.21; 95% CI, 0.09-0.50), more than 30 days from death (OR, 0.37; 95% CI, 0.17-0.81), and having a hematologic oncologist present for the discussion (OR, 0.40; 95% CI, 0.21-0.77) were correlated with lower odds of admission to an intensive care unit in the final 30 days before death. In addition, patients who had the initial goals-of-care discussion more than 30 days before death were less likely to die in a hospital (34.9% vs 59.9%; P =.0002; unadjusted OR, 0.36; 95% CI, 0.21-0.62).
The odds of enrolling in hospice more than 3 days before death were significantly increased if a hematologic oncologist was present at the first discussion on goals of care (OR, 3.07; 95% CI, 1.58-5.96).
The authors suggested that “one way to promote such person-centered care that honors individual preferences of patients with blood cancer at the [end of life] is through timely conversations [about goals of care] that occur in the outpatient setting and, importantly, involve hematologic oncologists.”
1. Odejide OO, Uno H, Murillo A, Tulsky JA, Abel GA. Goals of care discussions for patients with blood cancers: Association of person, place, and time with end-of-life care utilization [published online October 8, 2019]. Cancer. doi:10.1002/cncr.32549