Background Haematological malignancies encompass a range of heterogeneous conditions. Despite treatment advances the prognosis of several patient cohorts remains poor. Such individuals more commonly receive active treatment in the weeks prior to death, require inpatient admission and die in hospital compared to those with non-haematological cancers. However, this has been shown to contradict patient expectations of end of life care.
Methods A retrospective audit of 30 deceased patients with haematological malignancies was conducted in a tertiary department. Patient notes informed the number of hospital admissions, clinician exploration of preferred place of care, treatment escalation decisions and involvement of palliative care services within the 12 months prior to death.
Results Patients died from their underlying malignancy in 83% of cases. At the time of death 97% had a DNACPR in situ; 55% of forms were signed in the 2 days prior.
Patients required a mean of 4 admissions. Dependence on supportive blood products, a higher incidence of neutropenic sepsis and aggressive treatments were several reasons thought to be accountable. Achievement of preferred place of care was associated with initiating these discussions earlier. Of the 26% of patients asked, none specified hospital. Involvement of palliative care services was highest in the 5 days before death; 40% of referrals were for end of life support.
Conclusions Clinicians recognise when patients with haematological malignancies are imminently approaching their last days of life. However, the repeated pattern of admission in those with a poor prognosis may represent missed opportunities to initiate earlier advance care planning which has been linked to an increase in achieving preferred place of care. Focus groups exploring the barriers to initiate such conversations and empower earlier communication was felt to be a more effective intervention than the introduction of a paper proforma. A subsequent re-audit to assess their value is recommended.
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