- In a prior trial, integrating palliative care with transplant care was superior to standard care at improving patients' quality of life, psychological distress and symptom burden during and after hospitalization for hemopoietic stem cell transplantation
- This secondary analysis of that trial determined the most common topics addressed by palliative care clinicians were rapport building, symptom management and coping; nausea, pain and diarrhea were the symptoms most commonly addressed
- The intervention group was more likely than the control group to use patient-controlled analgesia (32% vs. 15%; P=0.02); use atypical antipsychotics (36% vs. 18%; P=0.01); and have standing orders for supportive care medications (74% vs. 57%; P=0.03)
- In exploratory analyses, though, neither patient-controlled analgesia nor atypical antipsychotics could be linked to the improvements in quality of life and symptoms of depression and anxiety patients reported two weeks after transplant
- These findings have implications for enhancing standard transplant care, as palliative care clinicians appear to aid patients with much more than medication management of symptoms
Because hemopoietic stem cell transplantation (HCT) involves an intensive course of treatment and a prolonged, socially isolated hospitalization, patients often experience physical and psychological symptoms that negatively affect their long-term quality of life (QOL) and mood.
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In a previous randomized, nonblinded trial reported in the Journal of Clinical Oncology, researchers at Massachusetts General Hospital showed that integrating palliative care into transplant care improved patients' QOL, psychological distress and symptom burden. Many of the benefits persisted until at least six months after transplant.
A secondary analysis of that study, published in Bone Marrow Transplantation, delved into the content of the intervention and exactly how it might have improved outcomes. Massachusetts General Hospital's Ashley M. Nelson, PhD, of the Department of Psychiatry, Joseph A. Greer, PhD, program director of the Center for Psychiatric Oncology & Behavioral Sciences, Areej El-Jawahri, MD, director of the Bone Marrow Transplant Survivorship Program, and colleagues consider the findings helpful to health care systems that would like to institute such an intervention—or simply improve standard transplant care.
The trial, conducted from August 2014 to January 2016, involved 160 adults admitted to Mass General for autologous or allogeneic HCT. They were randomly assigned to inpatient palliative care integrated with transplant care or standard transplant care.
In the intervention arm, palliative care physicians or nurse practitioners met with patients within 72 hours of enrollment for an initial consultation, then at least twice weekly throughout the transplant hospitalization. The control group received supportive care measures instituted by the transplant team.
Content of the Intervention
- Palliative care clinicians spent an average of 59 minutes with patients during the initial consultation, 77 minutes combined during week 1, 59 minutes combined during week 2 and 52 minutes combined during week 3
- After 73% of visits, palliative care clinicians communicated with the transplant team in person or by phone or email
- The most common topics addressed across all palliative care visits with patients were rapport building, symptom management and coping with HCT
- Nausea, pain and diarrhea were the symptoms most commonly addressed (89%, 73% and 48% of patients, respectively) with counseling or medication
- Constipation, fatigue, insomnia and anxiety were addressed in 25%–28% of patients
Supportive Care by Study Arm
The intervention group was more likely than the control group to:
- Use patient-controlled analgesia (32% vs. 15%; P=0.02)
- Use atypical antipsychotics (36% vs. 18%; P=0.01)
- Have standing orders for supportive care medications (74% vs. 57%; P=0.03)
Supportive Care As Mediators of Outcomes
In exploratory analyses, neither patient-controlled analgesia nor atypical antipsychotics could be linked to the improvements in QOL and symptoms of depression and anxiety patients reported two weeks after transplant.
Rationale for Early Support
Patients who undergo HCT often experience a high symptom burden for months or years afterward. Integrating palliative care into the initial hospitalization gives them an early opportunity to develop trusting relationships with clinicians.
This study may be a useful blueprint for improving standard transplant care because palliative care clinicians appear to aid patients with much more than medication management of symptoms. One possibility is that their focus on coping provides patients with skills to manage their treatment more effectively.
Learn more about the Bone Marrow Transplantation Survivorship Program
Refer a patient to the Mass General Cancer Center