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Original Investigation
November 22/29, 2016

Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell TransplantationA Randomized Clinical Trial

Author Affiliations
  • 1Massachusetts General Hospital, Boston
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Duke University School of Medicine, Durham, North Carolina
  • 4Fred Hutchinson Cancer Research Center, Seattle, Washington
JAMA. 2016;316(20):2094-2103. doi:10.1001/jama.2016.16786
Key Points

Question  What is the effect of an inpatient palliative care intervention on the quality of life of patients with hematologic malignancies during hospitalization for hematopoietic stem cell transplantation (HCT)?

Findings  In this randomized clinical trial of 160 adults, patients assigned to an inpatient palliative care intervention reported a 14.72-point decrease in their quality of life from the time of admission for HCT to week 2 of hospitalization compared with a 21.54-point decrease in quality of life for patients assigned to transplant care alone, a statistically significant difference.

Meaning  Among patients with hematologic malignancies undergoing HCT, involvement of palliative care, compared with transplant care alone, led to a smaller decrease in quality of life at 2 weeks after transplantation.

Abstract

Importance  During hospitalization for hematopoietic stem cell transplantation (HCT), patients receive high-dose chemotherapy before transplantation and experience significant physical and psychological symptoms and poor quality of life (QOL).

Objective  To assess the effect of inpatient palliative care on patient- and caregiver-reported outcomes during hospitalization for HCT and 3 months after transplantation.

Design, Setting, and Participants  Nonblinded randomized clinical trial among 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers (n = 94). The study was conducted from August 2014 to January 2016 in a Boston hospital; follow-up was completed in May 2016.

Interventions  Patients assigned to the intervention (n=81) were seen by palliative care clinicians at least twice a week during HCT hospitalization; the palliative intervention was focused on management of physical and psychological symptoms. Patients assigned to standard transplant care (n=79) could be seen by palliative care clinicians on request.

Main Outcomes and Measures  Primary: change in patient QOL from baseline to week 2; secondary: patient-assessed mood, fatigue, and symptom burden scores at baseline, 2 weeks, and 3 months after HCT and caregiver-assessed QOL and mood at baseline and 2 weeks after HCT.

Results  Among 160 enrolled patients (mean age, 60 [SD, 13.3] years; 91 women [56.9%]; median hospital stay, 21 days) and 94 caregivers, 157 (98.1%) and 89 (94.7%), respectively, completed 2-week follow-up, and 149 patients (93.1%) completed 3-month follow-up. Patients in the intervention group reported a smaller decrease in QOL from baseline to week 2 (mean baseline score, 110.26; week 2 score, 95.46; mean change, −14.72) compared with patients in the control group (mean baseline score, 106.83; week 2 score, 85.42; mean change, −21.54; difference between groups, −6.82; 95% CI, −13.48 to −0.16; P = .045). Among the secondary outcomes, from baseline to week 2, patients in the intervention group vs those in the control group had less increase in depression (mean, 2.43 vs 3.94; mean difference, 1.52; 95% CI, 0.23-2.81; P = .02), lower anxiety (mean, −0.80 vs 1.12; mean difference, 1.92; 95% CI, 0.83-3.01; P < .001), no difference in fatigue (mean, −10.30 vs −13.65; mean difference, −3.34; 95% CI, −7.25 to 0.56; P = .09), and less increase in symptom burden (mean, 17.35 vs 23.14; mean difference, 5.80; 95% CI, 0.49-11.10; P = .03). At 3 months after HCT, intervention patients vs control patients had higher QOL scores (mean, 112.00 vs 106.66; mean difference, 5.34; 95% CI, 0.04-10.65; P = .048) and less depression symptoms (mean, 3.49 vs 5.19; mean difference, −1.70; 95% CI, −2.75 to −0.65; P = .002) but no significant differences in anxiety, fatigue, or symptom burden. From baseline to week 2 after HCT, caregivers of patients in the intervention group vs caregivers of patients in the control group reported no significant differences in QOL or anxiety but had a smaller increase in depression (mean, 0.25 vs 1.80; mean difference, 1.55; 95% CI, 0.14-2.96; P = .03).

Conclusions and Relevance  Among adults at a single institution undergoing HCT for hematologic malignancy, the use of inpatient palliative care compared with standard transplant care resulted in a smaller decrease in QOL 2 weeks after transplantation. Further research is needed for replication and to assess longer-term outcomes and cost implications.

Trial Registration  clinicaltrials.gov Identifier: NCT02207322

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