IAHPC research advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
Chin-Yee, Taylor, Downar, Tanuseputro, Saidenberg. J Palliative Medicine. Published online 21 March 2019. DOI: 10.1089/jpm.2018.0605
Red blood transfusion — also the transfusion of plasma, platelets, and neutrophils — is a controversial practice in palliative care. The argument for its practice is the promise of symptom control, mostly fatigue caused by anemia. However, the evidence does not support this therapy at the end of life1, 2 and the risk for this population is not clear, which complicates the decision-making process. In addition, red blood is a valuable resource that can save life and should be used in a considered way3 for the benefit for the patient.
Chin-Yee and colleagues used a self-administered survey to explore current transfusion practices, attitudes, and factors that influence the decision to transfuse among specialist palliative care physicians in Canada. For patients with ‘solid tumors and hematologic malignancies, respectively, 79% and 82% of respondents [of the 62 physicians who received the survey, 29 responded] reported prescribing blood transfusion; 59% and 46% reported that they would seldom recommend its discontinuation. Influential decision-making factors included: symptoms of anemia (97%), bleeding (62%), low hemoglobin (52%, of which 87% indicated a hemoglobin threshold <70 g/L), and pressure from patients/families (48%). Physicians routinely reassessed patients for symptomatic improvement following transfusion, but 72% did not use an objective symptom scale. Twenty-six (90%) of respondents believed that transfusion provided symptomatic benefit; the majority had observed adverse reactions to transfusion. Most perceived a lack of evidence to guide transfusion therapy in palliative care, and 79% indicated willingness to enroll their patients in a trial aiming to address this question.’
There is not yet clear guidance regarding transfusion or the decision-making process, but it is apparent that more than clinical arguments currently play a role. I presume that not only the pressure of the family, but also the physician’s need to do something, influence the decision. More research is required!
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References
“What, all things considered, should happen in this situation?” This is the one question that every family physician can ask — at every clinical encounter — to improve advance care planning conversations.
A reflective case study in family medicine advance care planning conversations.
Journal of the American Board of Family Medicine, 2019;32(1):108-114.
The three articles below, selected from Barry R. Ashpole’s weekly Media Watch column, underscore the direct correlation between the quality of end-of-life care and the quality of communication.
The Lancet, 2019;393(10176):1072. ...[T]here is little evidence-based practical guidance grounded in an understanding of the developmental stage of a child and the need for, and effect of, information about life-threatening conditions. Even less evidence is available on how best to communicate with children when their parents have a life-threatening disease. Two articles in this week’s issue of The Lancet review the literature and provide communication principles and examples based on an integration of the available research and the authors’ own clinical and academic perspective. DOI: 10.1016/S0140-6736(19)30572-0
JAMA Oncology | Online – 14 March 2019 – Conversations about prognosis, priorities, and end-of-life care are stressful, difficult, and vital... The Serious Illness Care Program (SICP) was developed to help oncologists improve the frequency, timeliness, quality, and documentation of discussions about these difficult issues. The SICP is a complex intervention (and a major undertaking) that includes training, coaching, and prompts for oncologists; information for patients and their families/caregivers; tools for identifying suitable patients and prompting conversations with them; and, a mechanism for documenting these discussions in the patient’s electronic medical record. DOI: 10.1001/jamaoncol.2019.0291
BMC Palliative Care | Online – 8 January 2019 – End-of-life (EoL) conversations are rarely initiated by care staff in long-term care (LTC) facilities... This study provides...evidence about factors that could improve care staff’s self-efficacy. As higher self-efficacy is associated with an increased likelihood of performing a certain procedure, nursing education programs should pay more attention to palliative care and EoL conversations in their curriculum and use more experiential/bedside learning methods to promote successful experience with this in an early stage of working life. Moreover, clear agreements about who should take responsibility for initiating EoL conversations should be made. DOI: 10.1186/s12904-018-0388-z
Barry R. Ashpole is a Canadian communications consultant and educator. Media Watch, intended as an advocacy, education, and research tool, monitors the literature on issues specific to the quality of end-of-life care. It is international in scope and distribution.
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