Patients who have hematologic cancers have often had at least one, if not more, stays in the ICU. “This means that they and their family members have a history of experiencing ups and downs and successful treatment so that they can leave the ICU,” says Colleen M. Gallagher, PhD, FACHE, chief and executive director of the section of integrated ethics in cancer care at The University of Texas MD Anderson Cancer Center in Houston.

Because of this, patients and families often have a hard time understanding that this time is different. “These patients sometimes are experiencing new cancers after the previous ones were successfully treated, giving them years of survival,” notes Gallagher.

A recent letter to the editor in the journal Bone Marrow Transplantation focused on the unique challenges of end-of-life care in patients with hematologic malignancies.1 Misconceptions among both patients and clinicians about the role of palliative care and its relationship to “aggressive treatment” contribute to high rates of aggressive interventions at the end of life, and a high proportion of in-hospital deaths, the authors wrote. The following factors hamper prognosis and management, the authors concluded:

  • the absence of clear transition points between curative and palliative phases of care;
  • the severity of treatment-related complications;
  • the potential, in many cases, for significantly life-prolonging transfusion support.

“Advance care planning helps in these situations because the patient, the people who love them, and the healthcare team have a common understanding of the goals and the ways in which these can be balanced with medical possibilities and limitations,” says Gallagher.

“An ethicist can assist at various stages in a patient’s cancer journey,” says Gallagher. “We can assist patients in exploring their own expectations and needs.” This is particularly important when the decisions get harder.

When patients are approaching the end of life, the ethicist can help frame questions in ways that may not have been thought about previously.

“Ethicists deal with value-laden decisions,” says Gallagher. Often, these go beyond the patient’s decisions about medical care. Decision-making also can involve the patient’s planning for what happens for those who live on.

“We can assist the patient, and often the family together, to look at legacy and responsibility — both of which are important to patients,” says Gallagher.

REFERENCE

  1. Eckhert EE, Schoenbeck KL, Galligan D, et al. Advance care planning and end-of-life care for patients with hematologic malignancies who die after hematopoietic cell transplant. Bone Marrow Transplant 2017 Mar 13. doi: 10.1038/bmt.2017.41. [Epub ahead of print]

SOURCES

  • Colleen M. Gallagher, PhD, FACHE, Chief and Executive Director, Section of Integrated Ethics in Cancer Care/Professor, Department of Critical Care and Respiratory Care, University of Texas MD Anderson Cancer Center, Houston. Email: CMGallagher@mdanderson.org.