Building Trust: Concurrent Use of Palliative Care and Bone Marrow Transplant

Early palliative care integrated with oncology care is increasingly becoming the standard of care for patients with advanced solid tumors, given the mounting evidence supporting this integrated care model.

Studies have shown that patients receiving early palliative care integrated with their oncology care derive multiple benefits, including improvement in their quality of life, symptom burden, psychological distress, and potentially overall survival. In addition, caregivers of patients with advanced solid tumors also appear to benefit from palliative care integration, with improvement in their depression symptoms and caregiving burden. Consequently, the American Society of Clinical Oncology (ASCO) released an updated statement recommending that all patients with advanced cancer – and their caregivers – should receive early palliative care services integrated concurrently with oncology care at the time of active treatment.

Despite these benefits, patients with blood cancers and those receiving potentially curative therapy with bone marrow transplantation (BMT) rarely utilize palliative care services. This lack of integration is likely due to multiple factors, including:

• Patients undergoing BMT are receiving intensive therapy with the goal of curing disease and palliative care has traditionally not been integrated in the care of patients receiving curative therapy.
• The uncertainty about prognosis in this population and the absence of a clear transition between curative phase and palliative phase of treatment leads to delays in thinking about utilizing palliative care.
• Patients with blood cancers often have a rapid and unpredictable trajectory of decline at the end of life.
• Misperceptions by BMT clinicians equating palliative care with ‘just end of life care’.
• BMT clinicians often lack exposure to palliative care, leading to some mistrust.

In a recent randomized clinical trial[1], many of these barriers to palliative care integration in BMT were surmounted. In this trial, patients with blood cancers who were admitted to the hospital for BMT were randomly assigned to receive palliative care integrated with their transplant care versus transplant care alone. Patients receiving the palliative care intervention met with a palliative care clinician within 72 hours of admission for their BMT. They were followed longitudinally with twice weekly visits by palliative care throughout their 3-4 week BMT hospitalization. Patients who received integrated palliative and transplant care reported improvement in their quality of life, symptom burden, depression, and anxiety during their transplant hospitalization compared to those who received transplant care alone. Remarkably, this brief inpatient palliative care intervention also led to a sustained improvement in patients’ quality of life, depression, and post-traumatic stress symptoms at least three months after BMT. This paradigm-shifting study demonstrated for the first time the benefit of early palliative care integration for patients with blood cancer undergoing BMT and (more generally) the potential role that palliative care can play in the care of patients receiving potentially curative therapy.

There are important lessons that can be learned from this trial to help promote palliative care integration in the care of patients with blood cancers and those undergoing BMT. Both BMT and palliative care clinicians gained important insights regarding their mutual collaboration throughout the study period.

• Palliative care clinicians have more tools in their toolbox for complex symptom management in this population receiving the most intensive treatments in oncology.
• Palliative care clinicians have substantial expertise in helping patients cope and adapt to their illness, as well as manage their expectations during the transplant process.
• Palliative care is about maximizing quality of life during and after disease treatment. Hospice is for end of life care.

• Palliative care clinicians learned the unique needs of patients undergoing BMT, and understand the conditioning chemotherapy regimens and expected side effects profile, as well as the overall illness trajectory to provide the highest quality care for this population.
• Palliative care clinicians gained a deeper understanding of the prognostic uncertainty facing patients with blood cancer who receive potentially curative therapy.
• The trial highlighted the importance of establishing trust and collaborative relationships between palliative care and BMT clinicians.

As we learn from these insights and expand the evidence for palliative care integration for patients with blood cancers and those undergoing BMT, we can discuss some general tips and guidance on the optimal strategies to promote integration:

• Start by breaking misperceptions about palliative care. The early integrated palliative and transplant care trial specifically focused on addressing physical and psychological symptom burden in patients undergoing BMT with curative intent. This focus helped correct misperceptions about appropriate timing for palliative care. It also allowed an opportunity to build trust between palliative care and BMT clinicians as they cared for patients collaboratively.
• Cultivate a collaborative environment by engaging palliative care clinicians, BMT clinicians, and nurses in discussing how to best structure an integrated care model and efficient workflow, and discuss barriers and concerns regarding such integration.
• Focus on the science and rationale for palliative care integration in cultivating trust. Discussing the substantial evidence of the potential benefits of integrated palliative and oncology care helped skeptical BMT clinicians understand the goals – enhance quality of life during disease treatment— of an integrated care model.
• Create opportunities for bi-directional learning between palliative care and BMT clinicians. Both teams bring substantial expertise and knowledge and can learn from one another to enhance patient care.

These measures likely played a critical role in the positive outcomes seen with our early integrated palliative and transplant care trial. Importantly, these measures created a cultural shift resulting in more routine palliative care integration for many patients with blood cancers who did not participate in the trial. BMT clinicians began reaching out to their palliative care colleagues for help in difficult symptom management and changing treatment decisions common in this population. By building trust and collaborative relationships in caring for patients and families together, we can and will continue to overcome barriers to palliative care integration in BMT.