Patients with blood cancers typically value time spent at home in their end-of-life care, however, health care systemts do not always prioritize this in their own quality measures.
Patients with hematologic malignancies spend fewer days at home compared with those with other cancers. However, researchers at Sunnybrook Health Sciences Centre in Toronto found predictors that may help patients with poor prognoses to spend more time at home and to ultimately improve their end-of-life care.
To improve the quality of end-of-life care, health care systems typically prioritize for patients to receive aggressive interventions such as chemotherapy, for patients to be admitted to intensive care units, the emergency room or hospital in general. However, when patients were asked what matters most, their priority was quite different.
“Measures typically reflect more what health systems prioritize and not what patients value most. So, if you ask questions to patients about what they value most at the end of life, almost invariably the answer is to spend as much time at home as possible,” Matthew Cheung, M.D., M.S., FRCP, associate scientist at Sunnybrook Health Sciences Centre, said in an interview with CURE.
Cheung and colleagues aimed to determine the number of days spent at home in the last six months of life — defined as 180 days minus the number of days in an acute care facility, an inpatient rehabilitation facility, skilled nursing facility or chronic care facility – in patients with hematologic malignancies. They also evaluated predictors of this time spent at home in end-of-life timeframe and the relationship between time at home and these aggressive measures prioritized by health care systems. Results were presented at the American Society of Hematology Annual Meeting and Exposition.
The researchers identified 6,792 adult patients who died of a hematologic malignancy from Jan. 2005 to Dec. 2013 within the Ontario Cancer Registry to determine patient variables and system level variable, such as palliative care consultation, that predicted for the number of days at home and identified trends over time.
Patients were on average 72 years of age at the time of cancer death, more than half were men (58 percent), and the majority were urban-based residents (85.4 percent). Patients were classified as having acute leukemias (16.1 percent), aggressive-histology lymphomas (27.9 percent), indolent lymphomas (28 percent), or “other” (28 percent). Most patients had a moderate- to high-risk for comorbidities, and 27 percent had received palliative care consultation prior to the last six months of life.
In the last six months of life, patients spent about 156 days at home, with 81 percent who spent more than 120 days at home. Increased age, male gender, an extended time period from diagnosis until death, and those who received palliative care consultation prior to the six months before end of life were predictors of spending more than 120 days at home.
Chueng commended the added benefit patients appeared to receive from palliative care consultations. “It hopefully reflects that at least those discussions might actually help with better preparedness for patients to spend more time at home.”
In contrast, women, those with higher educations, patients with more comorbidities and those who required transfusions were less likely to spend more time at home.
Cheung highlighted these predictors are important for physicians to understand in order to help those patients who want to spend more time at home at end of life. “We want to help a patient spend more time at home, and that might be someone that we involve palliative care earlier on or have earlier discussions about how we can help with their comorbidities to help them spend time at home.”
First and foremost, the patient must value days at home as an outcome in order for physicians to have discussions around end-of-life care. However, support systems also have an effect on these outcomes.
“Really at the end of the day it is not just an individual’s wish and circumstances, it is really kind of this whole circumstance of this network of people around the patient and whether that is adequate to support the patient at home,” Cheung said. “It really is important to involve the caregiver or sometimes multiple caregivers — both family, friends, and even paid caregivers – and whether that is an adequate support for the patients if they wish to be at home.”