Medical Technology

Talk Early to Patients With AML at risk of high-risk about the end of Life

End-of-life conversations are often too late in the treatment of high-risk acute myelogenous leukemia as per an review of 200 patients at Massachusetts General Hospital and the Dana Farber Cancer Institute, Boston.

The prognosis isn’t favorable for those with high-risk AML which is identified in the study as either relapsing/recurrent disease or a diagnosis made after the age of 59. Almost 60% of the patients (114) died within the seven years of study, which started in 2014.

It is important to discuss the end-of-life choices while patients are still capable of making them be able to, so families don’t have to guess what the level of their loved ones’ final care to be. The lead researcher Hannah Abrams is an intern medicine resident at Massachusetts General. She presented her findings at the annual meeting of the American Society of Hematology.

Discussions on end-of-life care are usually too late. The study team discovered that nearly 40% (45/114) of patients who passed away during the study were not involved in their final code choices that were typically to administer only comfort care. Many patients were too ill to participate; the average time between the last code change and death was only two days.

Abrams said she’s seen how families suffer when patients don’t address the issue prior to their arrival. “Witnessing that has made it evident to me that this is something I must be looking at. She stated that it was essential to have these conversations in the beginning.

When asked for comment, hematologist-oncologist Toby Campbell, MD, chief of palliative care at the University of Wisconsin, Madison, agreed.

He described this as an “missed chance for patient autonomy, and self-determination.” Patients with high-risk AML frequently experience rapid changes in their clinical condition which can be shocking to everyone. Healthcare professionals should take more steps to prepare families and patients rather than allowing them to be awed,” Campbell said.

One reason, Abrams said, is that discussions about the end of life can slip in the midst of urgent discussions about chemotherapy options and other matters.

“One of the most important steps to make this more feasible is to plan and pay for time in clinic for this to happen,” she said, noting a need to carve out and secure “15 minutes for patients and clinicians to discuss this.”

Another factor is that patients tend to be overly optimistic about their prospects and therefore, discussions about their end-of-life plans don’t seem as pressing. Educational materials on the meaning of different code options and when they’re appropriate may help, Abrams said.

Mikkael Skeres MD, chief of the University of Miami’s division of Hematology, stated that the psychological impact of discussing end-of-life issues early is significant.

Sekeres moderated Abrams’ presentation at meeting. “Sometimes it is necessary to have a sentinel event such as an ICU stay prior to when some people will be willing to engage in that discussion.”

Abrams and her team also disclosed that 86.0% of patients at diagnosis were full-coded and 8.5 percent had limitations to life-sustaining therapies. Overall, 57 percent (114/200) of patients had the status change of their code, with a median of two transitions during their illness.

For patients who died due to age, old age and the use of non-intensive chemotherapy were correlated with earlier discussions about the status of codes.

The next step in the project is to determine whether palliative care consults yield earlier discussions and greater participation of patients.

The study was not funded commercially and Abrams Campbell did not have any disclosures. Sekeres is an advisor for Novartis, Takeda and BMS.

This article originally appeared on, part of the Medscape Professional Network.

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