Sunday, March 1, 2009

Bone Marrow Transplantation & Palliative Care

I'm guessing that most of our readers do not peruse Bone Marrow Transplantation every month, but you might want to check out this article. It was written by the BMT & palliative care folks at the Massey Cancer Center, Virginia Commonwealth University. Yes, that would include Tom Smith, well known oncologist & palliative care doc at VCU.

Significant inroads have been made in the historic emergency room and ICU resistance to palliative care and end-of-life care. BMT may be one of the last clinical areas to incorporate palliative care & end-of-life care into unit protocols and practice. Indeed, the authors of this paper believe that it is the first of its kind in the BMT literature.

Interestingly, the paper starts with a few epithets that hypothetical BMT and palliative care clinicians might launch at each other, demonstrating apparently radically different world-views.

The real message, of course, is not the least bit radical: BMT and palliative care were made for each other--unless either group chooses to over-emphasize the end-of-life care part of palliative care, which is very likely the crux of the perceived divide--one statement made is that "transplant physicians may not realize that PC is not the same as hospice care." Another recent article, a study at MD Anderson on which I will blog in a few days, suggests that large percentages of medical oncologists and mid-level providers confuse palliative care and hospice care. So we are hearing from two major cancer centers with well-known palliative care programs that the folks inside their own institution don't know what they do and represent.

Even if there are very different world views--the same is true of patients, too--there is plenty of room for overlap and collaboration. Despite the contention that "the two fields should be complementary" and "the fields should mesh well," there have been no significant attempts to explore the relationship. This is one group's attempt to do so. Stylistically and rhetorically, I wish they had used the following at the beginning of the paper rather than the end: "When and where to perform PC for BMT patients? This question can be answered, 'Well of course . . . all of the time and everywhere!'"

A very suprising statement (to me, anyway) is that there have been no published papers on the symptom experience of BMT patients since 1993. There has been considerable advancement in this specialty, including improvements in symptom management, since then. It would seem about time to get a good picture of symptoms and symptom management in "modern" BMT. They suggest that a systematic approach to symptom assessment and management, previously demonstrated at both Anderson & VCU in non-transplant patients, would be applicable in the BMT setting.

The next section of the paper reviews treatment approach for expected symptoms (e.g., mucositis, N/V, diarrhea, etc.). Then there is fairly extensive discussion of areas that may be less familiar to some in the transplant community: communication, especially regarding prognosis; family education and support; and transition to end-of-life care and hospice. A very interesting and too-short section addresses the problems specific to transplant patients that make hospice referral difficult. As an example, severe GVHD may well be more appropriately managed from a symptom perspective in an intensive care setting. Support for MICU staff as well as intensive palliative care for the patient and family are necessary in this circumstance.

There is little in this paper that will be new to most folks actively engaged in palliative care. However, the paper was written for the transplant audience. It may very well be the first introduction to palliative care as a concept and practice that many in this audience have had. As such it is a valuable & valiant foray into a relationship that will be new for those in both specialties.

Chung HM, Lyckholm LJ, Smith TJ. Palliative care in BMT. Bone Marrow Transplant. 2009 Feb;43(4):265-73. doi:10.1038/bmt.2008.436

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