Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study.

Dorothy Mccaughan,Anne C Garry,Russell D Patmore,Eve Roman,Martin R Howard,Debra A Howell,Miriam J Johnson,Alexandra G Smith

doi:10.1016/j.ejon.2019.02.003

Abstract

PurposePatients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients’ places of care and death.MethodQualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach.ResultsFive inter-related factors were identified as contributing to the likelihood of patients’ receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home.ConclusionsHospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.

Highlights

There are over sixty haematological malignancy subtypes (Arber et al, 2016; Swerdlow et al, 2016), and these ‘blood cancers’ are often categorised as leukaemias, lymphomas and myeloma
The haematology nurses perceived hospital death as likely to predominate amongst their patients due to a complex interplay of interrelated factors
Inter-related factors perceived as influencing likelihood of hospital death are summarised in Fig. 1 and described below, with verbatim quotes

Summary

Introduction

There are over sixty haematological malignancy subtypes (Arber et al, 2016; Swerdlow et al, 2016), and these ‘blood cancers’ are often categorised as leukaemias, lymphomas and myeloma. Many are indolent (e.g. follicular lymphoma and chronic lymphocytic leukaemia), and behave like chronic diseases, others (e.g. acute myeloid leukaemia) are often aggressive (NICE, 2003). Management varies by subtype: some are curable with intensive, toxic chemotherapy, associated with long periods of hospitalisation; others are incurable from diagnosis and managed with intermittent or continuous oral chemotherapy (NICE, 2003). Clinical pathways and prognosis depend on the disease, its response to treatment, and the patient's characteristics (Roman et al, 2016; Smith et al, 2015, 2018a). Prognostication is notoriously difficult (Auret et al, 2003; Hui et al, 2016; Odejide et al, 2014), which has European Journal of Oncology Nursing 39 (2019) 70–80 significant implications for the timely organisation and delivery of end of life care (LeBlanc and El-Jawahri, 2015)

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Discussion

Conclusion