Palliative care in BMT - Nature

Bone Marrow Transplantation (2009) 43, 265–273 & 2009 Macmillan Publishers Limited All rights reserved 0268-3369/09 $32.00

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REVIEW

Palliative care in BMT HM Chung1,2, LJ Lyckholm1,3 and TJ Smith1 1

Department of Internal Medicine, Division of Hematology/Oncology and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA; 2Bone Marrow Transplantation Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA and 3Department of Internal Medicine, Division of General Medicine and Bioethics, General Medicine and Bioethics, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA

The field of high-dose therapy and SCT has made many advances in the past several years and the success rates have been steadily increasing as newer therapies emerge and improvements in supportive care continue to improve patient survival and cure rates. There still remains a mortality risk for high-dose therapy and the need for palliative care becomes more apparent as the focus also incorporates quality of life in all facets of cancer treatment and care. This paper reports on the lack of literature available on palliative care into the BMT and explores areas of future research in the integration of these two fields of medicine. Bone Marrow Transplantation (2009) 43, 265–273; doi:10.1038/bmt.2008.436; published online 19 January 2009 Keywords: palliative care; hospice; symptom management

Introduction Transplanters: ‘Here comes the Death Squad.’ ‘The palliative care people say ‘In fact, there IS something we can do.’ It’s just not what my patient came here for—to be cured.’ ‘A 6% chance of cure is better than a 0% chance of cure.’ Palliative Care Types: ‘It sure would be nice to see these patients earlier. Like when they could talk. Hard to plan a life review when she’s comatose and has 48 h to live.’ ‘Well, what about the 94% who go through living hell in order to benefit that 6%? Shouldn’t they know the odds, and what they’re getting into, because I think some of them would choose differently.’

‘Every transplant program already has a palliative care unit where people go to die. The MICU.’ One of us (HC) was lecturing on methods to integrate palliative care (PC) concepts into BMT when approached by a transplant colleague. His comment was ‘Isn’t that an oxymoron?’ The divide can be sharp with transplanters thinking that PC is the ‘death squad’ and PC thinking that transplanters do not communicate goals or effectiveness of treatments truthfully, and do not know how to relieve common symptoms. The two teams rarely meet, except when a patient is dying, often after a long intensive care unit (ICU) stay. In fact, the two fields should be complementary. High-dose chemotherapy and SCT is an established way to cure or remit serious illnesses. Approaches such as nonmyeloablative, reduced intensity, cord blood and double cord blood transplant are increasingly effective with less toxicity. The main focus of SCT in years past was to give patients ‘a second chance’ when all else had failed. But over the years, this mantra has slowly shifted to more of ‘Do everything possible to obtain remission and a chance of cure without sacrificing too much quality of life.’ Transplant teams have been at the forefront of supportive care with emphasis on management of infections, mucositis,1 nutrition,2–6 pain during transplant7–9 and even truthful communication about prognosis.10 Transplant clinicians may not realize that PC is not the same as hospice care. PC is care given to seriously ill patients alongside usual medical and surgical care (Box 1). The fields should mesh well, but there has been no exploration of that relationship. The only articles published were a case report of PC for a patient undergoing transplantation for CML,11 death and dying issues for nurses caring for patients undergoing BMT12 and reviewing educational standards in BMT and PC.13 Toxicities are considerable, communication that is both hopeful and Box 1

Correspondence: Dr HM Chung, Division of Hematology/Oncology and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, 1300 E College Street, North Hospital, 10th Floor, BMT Unit, Richmond, VA 23298-0157, USA. E-mail: [email protected] Received 4 August 2008; accepted 23 November 2008; published online 19 January 2009

What is palliative care? As stated by the National Consensus Project, palliative care is ‘The goal is to prevent and relieve suffering and to support the best quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies.’ (145, Anonymous) Also described by the Center to Advance Palliative Care as, ‘Interdisciplinary care that aims to relieve suffering and improve quality of life for patients with advanced illness and their families.’ (143, Anonymous)

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realistic is a challenge and relapse continues to be a problem. With that lack of documented information noted, we sought to explore how PC and SCT could or should interact.

Symptom management Symptom assessment and management There have been no recent attempts to assess the symptoms that BMT patients experience. One 1993 paper recorded symptoms rated by 30 patients compared to symptoms rated by nursing staff during a BMT. It was reported that nurses underestimated their patients’ symptoms, and thus might not be expected to relieve them.14 There is good evidence from two cancer centers that PC is effective in reducing cancer symptoms even for patients with hematologic malignancies. Figure 1 shows the improved symptom measures with PC consult at MD Anderson Cancer Center,15 similar to findings at our center with nontransplant cancer patients.16 A PC approach of multiple symptom assessment every day to uncover hidden symptoms, with an algorithm-based plan for treatment, is planned.

ESAS 0-3

Pain The use of patient-controlled analgesia (PCA) and continuous i.v. morphine or other opioids for pain in BMT showed similar benefit, but, less consumption when patients had control of their medication administration.8,9,17 Comparison of the different opioids was performed in transplant patients in 1996 by Coda et al.,7 who recommended that morphine be the first choice of opioids for patients undergoing high-dose therapy and transplantation. As in PC, due to its effectiveness and easy titration as well as dose conversion to other narcotic pain medications, PCA

morphine has become the standard for pain management for BMT programs.18

Mucositis Oral mucositis can significantly impact quality of life (QOL) and survival. Besides the pain, there is also increased risk for infection, altered nutritional status and even increased risk of GVHD by way of epithelial disruption.19 One of the biggest challenges in studying ways to alleviate mucositis and pain associated with mucositis was developing an objective evaluation method that was consistent for comparison from one patient to another. Factors such as oral pain assessment, opioid use, oral intake and objective scoring of oral mucositis have been proposed.20 Recently, a new outcome measure has been developed and validated, the Patient-Reported Oral Mucositis Symptom scale.21 This scale may reflect more accurately patients’ symptoms and the efficacy of mucositis treatments. An effective method to prevent mucositis was reported in 2004 by multiple cancer centers participating in a trial of keratinocyte growth factor, palifermin.22 Grades 3 and 4 mucositis occurred in 63% of patients receiving palifermin compared to 98% of those receiving placebo. The median duration of mucositis was also decreased by greater than 50%, 3–4 days in those receiving palifermin compared to 9 days in those receiving placebo. There was also a significant decrease in the use of i.v. narcotics for pain control and need for parenteral nutrition in patients receiving palifermin. The cytoprotectant amifostine may help in the prevention and treatment of oral mucositis.23 In this study, 35 patients received amifostine as part of the preparative regimen: 40% of patients experienced severe mucositis compared to 94% of patients in a historical control group. Supersaturated calcium phosphate mouth rinse in combination with fluoride rinse was compared to fluoride rinse

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0 1st day Figure 1

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Symptoms are improved by palliative care (PC) consultation or transfer at MD Anderson Cancer Center. Edmonton Symptom Assessment Scale 0–10. Data from Elsayem et al.15

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alone and was found to show statistically significant reductions in duration of mucositis (3.72 vs 7.22 days), duration of pain (2.86 vs 7.67 days), dose of morphine (34.5 vs 122.8 mg) and days of narcotic use (1.26 vs 4.02).24 There are other PC methods to treat or prevent mucositis. Glutamine is a nutritional additive that may accelerate the healing process in mucositis.5,6 Oral cryotherapy can help prevent oral mucositis; in 80 patients undergoing high-dose therapy and autologous SCT there was a clinically significant reduction in the severity of mucositis as well as less use of i.v. narcotic for pain relief in those randomized to oral cryotherapy compared to those receiving standard oral care.25 A 1995 study showed clinically significant reduction of mucositis pain in those patients with cancer who utilized relaxation and guided imagery or cognitive behavior training26 but the study has not been replicated. Further work combining PC and BMT methods is needed.

Nausea and vomiting Standard antiemetics have been used in high-dose therapy including phenothiazines, benzodiazepines and serotoninuptake inhibitors with varying degrees of success. Although not studied extensively in patients undergoing high-dose therapy, haloperidol27 and olanzapine28 have been beneficial in patients with refractory nausea and vomiting. Many of the methods used in PC and BMT are the same. Other nontraditional treatment options such as scopolamine showed efficacy compared to usual antiemetic therapy in those patients receiving highly emetogenic chemotherapy including cisplatin in early trials29 and in combination with other antiemetics.30,31 Although more effective for motionrelated nausea and vertigo, complementary treatments, such as acupressure bracelets studied in 739 patients who had improvement in nausea on the day of chemotherapy,32 guided imagery as discussed in a pilot study twice a week during inpatient transplantation,33 and healing touch.34 Gastroparesis of uncertain etiology may be a primary cause of nausea in BMT.35 Eagle et al.36 evaluated 151 transplant patients during a 1-year period and found that gastroparesis was a significant cause of persistent nausea in 12% of patients. Factors such as age, conditioning regimen, CMV antigenemia and acute GVHD were not significant; however, receiving allogeneic transplantation was a significant factor. Compared with those receiving CYA, patients who were given tacrolimus tended to have a decreased incidence of gastroparesis, a finding that trended toward significance.37 This was most likely due to the prokinetic properties of tacrolimus. We could find no reports evaluating the efficacy of common PC measures such as erythromycin, metoclopramide or acetylcysteine in patients undergoing high-dose therapy and suffering from gastroparesis.38 Nutrition, anorexia and weight loss The use of total parenteral nutrition (TPN) in BMT was first reported in 1980 by Schmidt et al.2 in the Journal of Experimental Hematology. TPN usage was later studied in 44 patients who were divided into two groups, those who received prophylactic TPN for nutritional support and

those who did not.39 Those patients who were given TPN upfront engrafted 3 days sooner than those who did not, a result that was significant and not related to initial cell dose infused. The use of TPN in transplantation was then studied in a randomized, prospective manner in 61 patients.3 Total 31 patients received TPN whereas the remaining 30 patients were continued on enteral feeding. The results of this study revealed that there was no difference in outcome from transplantation measured in days to recovery of counts and length of hospitalization, and there was an increased risk of morbidity due to increased use of diuretics (11 vs 4 days), increased incidence of hyperglycemia (9 days vs 2 days) and more catheter removals (13 vs 3) due to complications from i.v. nutrition, not to mention the cost of i.v. TPN being 2.3 times higher than enteral feeding. The authors of this study recommended that the use of TPN be restricted to those who could not tolerate enteral feedings. Long-term difficulties in appetite, taste and weight maintenance were common in the year after transplantation especially after TBI but we could not find any report of effective interventions.40

GVHD GVHD can lead to increased morbidity and mortality. Several methods were designed in hopes of controlling GVHD but it remains a significant problem as some amount of GVHD is necessary. Many of the systemic therapies for GVHD for symptoms have been tried in addition to topical steroids and calcineurin inhibitors with varying degrees of success. Until these are more successful, we are left with standard symptom control measures such as the National Comprehensive Cancer Network Guidelines for the prevention and management of oral mucositis in cancer care,41 which include those cited in the Mucositis section. Diarrhea Whether due to mucosal disruption from high-dose chemotherapy and/or radiation, or from GVHD, diarrhea can be a severe and life-threatening complication from BMT due to electrolyte loss, malnutrition and bleeding. Medications such as loperamide and diphenoxylate have been used with varying degrees of success. For more severe diarrhea, somatostatin analogues such as octreotide have been reported and used with success including the first reported case in 1990 in a 39-year-old man with grade 3 GVHD of the gut and responding to a 10-day course of octreotide.42 Other PC measures have not been applied.43 Transfusion dependence If myeloablative therapy fails to cure the disease, there are still some patients who will continue with good QOL with occasional transfusions. The decision then lies with the transplant team, physician, patient and patient’s family about the merits of ongoing transfusions and allocation of resources. A report in 2007 regarding the cost of transfusions in those patients with hematological diseases in hospice care in Italy found that those who were outpatient had less costs than those requiring inpatient hospital care depending on the frequency of transfusion and disease Bone Marrow Transplantation


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status.44 Another study showed patients in eight hospices in the United Kingdom that allowed transfusions on an outpatient basis had significantly longer survival (104 days) vs those patients that required transfusions on an inpatient basis (42 days),45 suggesting that removing barriers to transfusion might increase end-of-life survival.

Communication Communication about medical prognosis Communication about the risks and benefits is vital to patients and families in understanding the seriousness of their illness and its treatment, but patients may find it hard to obtain information about the benefits and harms of chemotherapy or when death is a possibility. In the largest study of 95 consecutive palliative chemotherapy patients, prognosis was discussed by only 39% of medical oncologists.46 In a large longitudinal study of hospitalized patients who were reasonably expected to die, the attending physician never discussed the possibility of death 62% of the time, and no one on the medical team discussed the possibility of death with cancer patients in 39% of cases.47 In a more recent study of 602 cancer patients, doctors only discussed imminent death with 31% of their dying patients.48 Doctors may also ‘collude’ in this hopefulness by giving such a wide range of outcomes that people choose the most favorable.49 The data are clear that patients for the most part want honest and truthful information. Krasuska et al.50 reported the need for patients to have a full discussion about BMT to alleviate some of the fears of high-dose therapy. Concerns about the possible harmful effects of prognostic information were studied to determine the preferences of parents with children who were being treated for cancer. In parents who found prognosis extremely or very upsetting, 87% wanted as much information as possible and 85% wanted it expressed numerically.51 In pediatric oncology, truthful prognostic disclosure did not destroy the hope of parents, even when the news was bad. In fact, those parents who were given more elements about prognosis found physician communication to be more hopeful even though the chance for cure was low.52 There is scant literature discussing transition from curative to palliative or end-of-life care specific to BMT. Patients are willing to risk a lot even when well informed and often have a different perspective than their health-care provider.53 Agrawal et al.54 noted that patients electing for phase I clinical trials would be willing to undergo a 10% chance of death from a new experimental drug with no proven track record. Lee55 documented that the patients with the worst chance of survival had the least understanding of realistic ‘odds’. In the prospective studies about prognosis for BMT, physicians and patients predicted treatment-related mortality fairly accurately when the actual mortality rate was less than 30%.55 Those patients who had an actual mortality rate greater than 30% tended to have greater optimism about their outcome than their physicians. In other words, the sickest patients with the least chance of survival were less likely to perceive their higher mortality rates and poor prognosis. Lee56 also found Bone Marrow Transplantation

that people who overestimated their odds of survival were no more likely to survive than those who were realistic or pessimistic. Similarly, in the Support Trial, patients who overestimated their survival lived no longer than those with pessimistic or realistic estimates, and were more likely to die of side effects of treatment, in hospital or in the ICU.57 There are data showing that the presence of advance medical directives is associated with better SCT outcomes,10 This study was performed to determine if discussing advanced care planning (ACP) had adverse effects on outcome and showed that those patients who did not discuss ACP actually had a greater risk of death (hazard ratio 2.11, P ¼ 0.001) than those who discussed it before transplantation. It may be difficult for patients to talk with their transplant doctors about advance medical directives. Lamont58 found that 69% of patients had discussed advance medical directives with someone. Of these patients, only 9% had discussed it with their oncologist and 78% of the rest did not want to talk about this with their treating oncologist. Surprisingly, 58% of them endorsed a strategy of discussing these difficult issues with the anonymous housestaff or hospitalist. This phenomenon was described by one of Lamont’s patients as ‘you go to an oncologist to be cured, not to be buried.’58 When the BMT doctor is new to the case, the same may apply, making it easier for the patient to discuss; if the BMT doctor has been caring for the patient during leukemia or lymphoma then it may require another health-care professional to guide the discussion. Further research is needed on how to initiate the conversation that leads to completion of advance medical directives, because the rate has not changed in past 20 years.59

Transitions to hospice and end-of-life care One of the main challenges of high-dose therapy is knowing when further medical management is futile, or that the harms of continued treatment outweigh the benefits. Many patients and physicians understand that aggressive measures are needed at times, and that those aggressive interventions become inherent in the thinking process and the day-to-day care. As transplanters, we have seen some of the best and the worst in the field of oncology and continue to be amazed at some of those who survive high-dose therapy and its complications. We have a good understanding from our own experience as to what patients may be able to achieve if they tolerate the process, and this is perhaps one of the leading difficulties in knowing when ‘modern medicine’ has reached its limits and when patients and/or physicians should yield to the disease. Emotions among patients and their family members begin to cloud the issue at times when deciding about palliative carey will they feel as though they are giving up too soon? They have made the decision to move towards high-dose therapy and transplantationy are they stopping too soon? Is it a sign of weakness or failure on the patient’s or the patient’s family’s perspective? ‘Will my doctor think I’m weak?’


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These emotions are present on the nursing side as well as staff members who are heavily involved in the care of their patients also see the occasional challenges of high-dose therapy, and questions arise such as ‘Are we giving up too soon? Should we give up? Should we have given up a long time ago? Is the doctor pushing too hard to continue with the process? Is the doctor not pushing hard enough?’ There are data about transitions from usual oncology care to hospice/end-of-life care that may be informative. Studies from the University of Michigan,60 Ireland Cancer Center,61 Dartmouth,62 Dana-Farber Cancer Institute (DFCI)63 and UC Davis:64 all show that introduction of the hospice team earlier in the disease process does not shorten survival or dismiss hope, but does appear to improve symptoms, and allow better planning even in phase I patients.54 Meyers et al.65 reported on 44 patients on phase III trials ‘simultaneously enrolled into a defined home care program focused on supportive care needs of the patient and family, as well as assessment of the toxicities of investigational therapy’ compared with 20 usual care (UC) patients. QOL improved but did not reach statistical significance. A total of 35 out of 44 simultaneous care (SC) group were referred to hospice compared to 8 out of 15 UC group (P ¼ 0.034) with longer mean but not median stay. Use of chemotherapy was not different, 2.5 cycles in both groups. The SC was well accepted by patients and caregivers. ‘Patients with advanced cancer at the time of enrollment onto investigational therapy should have made an explicit transition to palliative care goals but often have not. In the current health care environment, patients with advanced cancer without curative potential may be forced by their health provider or health insurer to choose between disease-directed therapies (including investigational therapy) or structured best supportive care programs’. SC may enhance coordination of care and facilitate patients’ explicit transition from curative to palliative intent. To validate this approach, a randomized comparative trial evaluating SC has been initiated but not yet been completed. Recognition of imminent death is also important and has recently been studied. Sullivan found that frequently when medical teams know when a patient is dying, they do not communicate that amongst themselves or to the patient. Prigerson and colleagues66 have recently reported that recognition of imminent death and making it explicitly known to the patient and family had good consequences and that the peacefully aware patient had lower rates of psychological distress and higher rates of ACP.

Impact of BMT on family To aid in the discussion of PC during the process of BMT with the patient, it is helpful to gain insight into the relationships with the significant other, family members and friends. Over the past few years, there have been several studies looking into the dynamics between patients undergoing high-dose therapy and their family members. Factors that may affect the caregiver and family members include diagnosis, prognosis, the process of transplantation and its risks and benefits, possibility of moving to another city or state and even changes in family roles.

The earliest paper discussing the impact of high-dose therapy on patient and family was reported in 1994 by Lesko.67 In this study, patients and their caregivers were followed through the process of BMT including pre-BMT evaluation and consultation, hospitalization and post transplantation care. Several factors were reported that affect better outcomes including awareness of the transplant process, preparation and understanding of possible side effects and toxicities including those that would affect body image and patients’ coping abilities. At McGill University, Dobkin et al.68 published a case report exploring the dynamics of one family’s interactions with an adolescent girl who underwent transplantation for leukemia. On discharge, the young girl exhibited many somatic symptoms that required her parents’ attention post transplantation. Dobkin et al.68 went on to discuss the many ways that family influences a patient’s recovery after high-dose therapy. Researchers at the University of Colorado reported psychological and immunological reactions of family members to patients undergoing BMT and found that partners/spouses had the highest scores on negative effects, escape-avoidance coping and psychological symptoms during the waiting period before BMT and steadily decreasing during the course of transplantation.69 The most stressful period was immediately after admission and before the BMT. There was significant correlation between anxiety, escape-avoidance coping and total percentage of T cells and of CD4 þ cells. At Northwestern University, researchers looked at psychosocial adjustment of patients and caregivers before high-dose therapy and transplantation using the Impact of Events Scale and found that caregivers reported more impairment in family relationships than patients. Information about the pre-BMT process appears to be critical to understanding the psychological impact that BMT can have on patients and their caregivers.70 At St Josephs Medical Center in Towson, MD, Grimm et al.71 discussed caregiver needs. A total of 43 caregivers were enrolled and assessed with the Caregiver Needs Survey, a modified version of the Home Cancer Caregiver Needs Survey. They were followed from the time of transplantation to 12 months after. Findings supported the importance of caregiver education of patient-care requirements and ongoing evaluation and intervention to meet the needs of the caregivers. An early study by Packman72 looked at the psychosocial impact of pediatric BMT on siblings. He looked at two different groups of siblings who were tested and whether they were a matched donor or nondonor. His study showed that sibling donors were much more likely to have significantly more anxiety, lower self-esteem and more adaptive skills in school than nondonors. His study also reported that one-third of siblings in each group reported a moderate level of post-traumatic stress. At DFCI, the parents of children with cancer who died between 1990 and 1997 were surveyed as well as the 42 pediatric oncologists who cared for them and found that shorter time to recognition of no chance for survival led to stronger emphasis at decreasing suffering and greater integration of PC.73 PC is beneficial for both patients and their families especially when curative measures are no longer an option.74 Bone Marrow Transplantation


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Problems specific to BMT that make transition to hospice difficult When and where to perform PC for BMT patients? This question can be answered, ‘Well of coursey all of the time and everywhere!’ But the crux of the question is when does comfort rather than longevity become the primary goal of medical care, that is, when medical management has reached its maximum efforts, without success, and end-oflife care begins. By now it should be clear that end-of-life care and PC are not synonymous, rather PC is provided at all times, both in tandem with very aggressive medical care, and particularly at the end of life. A challenge that patients undergoing high-dose therapy may face is not being able to leave hospital without the consequence of a much-shortened outlook due to severe infections and transfusion dependence. Indeed, there are cases of GVHD that are very severe and are beyond the scope of family members and even inpatient hospice units. This is where the transplant unit staff and unit must be prepared to accept those patients who cannot leave hospital and are not able to be cared for elsewhere and adjust to the shift in ‘pushing aggressively forward’ to providing the best comfort measures possible for the dying patient. One must be mindful that unit staff may need significant assistance in adjusting their own goals of care for the patient, as that transition can be confusing and create moral and psychological distress among the nursing and other patient care staff. Patients dying of GVHD may require high dose of continuous narcotics such as morphine, hydromorphone or fentanyl. Use of multiple antirejection drugs such as methylprednisolone, calcineurin inhibitors, mycophenolate and targeted protein inhibitors such as dacluzimab, sirolimus, denileukin diftitox and experimental therapy must be utilized to preserve QOL and treat pain and discomfort. None of these are inexpensive drugs were anticipated in the hospice benefit. Patients are often given transfusions of RBCs and platelets when high-dose therapy fails. Although hospice providers often view these interventions as ‘aggressive,’ patients and their families see them as part of usual medical

care.75 One study showed that over 50% of terminally ill cancer patients had subjective improvement in well-being after transfusion, unrelated to pre- and post-treatment hemoglobin levels.76 Although transfusions are expensive, cannot be done at home by most hospices and are not easily covered under the Medicare hospice benefit, they may provide significant relief and should not be ruled out as a palliative measure. It may be important to discuss this with the hospice provider when enrolling the patient.

Conclusions BMT and PC seem like obvious partners. BMT providers may think of PC as an extension of hospice, but it is different—and should be considered as concurrent with aggressive care for seriously ill patients. PC has been shown to improve symptoms in hospitalized patients,77,78 help with the transitions of cancer patients to hospice care;61 and reduce the costs for those dying in hospital.15,79–83 We propose a new model (Figure 2) that allows incorporation of PC into BMT from the beginning. This would include more explicit patient information about the odds of treatment benefit and risks, communication about progress including recognition of death when it is likely and aggressive symptom management. Andorsky et al.84 evaluated the relationship of QOL before transplantation and whether patients had a quicker, stronger recovery after high-dose therapy. They reported that pretransplantation self-reported physical and mental health were more strongly associated with QOL after high-dose therapy than the more usual clinical predictors such as age and disease risk.84 Tools such as a symptom assessment scale (Functional Assessment of Cancer Therapy—Bone Marrow Transplant85) or the modified Edmonton Symptom Assessment Scale (m-ESAS) scale (Figure 3) may be helpful in allowing recognition of usual symptoms including overlooked ones as fatigue, depression and dyspnea. Incorporating this into a table used during usual rounds in standard chart format may be helpful in focusing the team on treatment of symptomatology on a consistent basis.

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271 Modified symptom assessment scale: To be rated as: 0 = none, 1 = a little bit, 2 = somewhat, 3 = quite a lot, 4 = very much, 7 = Refused

Reported by:

Pain: current___, minimum___, maximum___ Anorexia____

Patient Caregiver RN MD

Tiredness________ Nausea__________ Depression _______ Anxiety __________ Drowsiness _______

Constipation____ Shortness of breath/dyspnea____ Secretions____ Unable to respond: Yes___ No____ Delirium: Yes____ No___

_ Figure 3 Symptom assessment scale used in palliative care (PC). From R01CA116227-01 (Meier). Impact of PC on outcomes of hospitalized patients.

There are many opportunities for research in PC and end-of-life issues for patients who have undergone highdose therapy and SCT. With increasing attention to this particular facet of medicine incorporated earlier in the course of BMT, optimal outcomes may be expected even if the goal of prolongation of life or cure is no longer attainable.

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