Intensity of Care at End-of-Life in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

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Introduction Allogeneic hematopoietic cell transplant (HCT) recipients are at a high risk for morbidity and mortality. The literature on quality and intensity of end of life (EOL) care and its association with advance directives and palliative involvement in this population is sparse. Objectives We sought to describe the EOL care in a cohort of allogeneic HCT patients who died and examine its association with advance directives, palliative care involvement, and patient characteristics. Methods A retrospective review of the medical record of patients who had received their allogeneic HCT (n=368) at our institution between 2013 and 2017 and died (n=129) was performed to collect information on place of death, hospital length of stay, number of admissions, intensity of care and palliative/ chaplain referrals. High intensity EOL care was defined as >1 of the following: death in the hospital, invasive procedure in the last week of life, use of mechanical ventilation in the last week of life, change to ‘no resuscitation’ code status in the last 3 days of life, length of stay >14 days in the last hospitalization, and >50% of last hospitalization in ICU. Association between baseline characteristics (age, gender, disease, disease risk, education, race/ ethnicity), presence of a living will and palliative medicine consult with intensity of EOL care was examined by a multivariable logistical model. Results Out of 129 deaths, 83(64%) had received EOL care at our institution and were included in the analysis. Median age of the patients in the cohort was 60 (range 21 to 76) years, 64% were male, 89% were white, 32% had received college or higher education and 66% had private insurance. 59% patients died in hospice (36% in inpatient hospice, and 23% in home hospice) and 40% in the hospital (23% in ICU and 17% on the floor). Figure shows indicators of intense EOL care in patients who died in hospital vs. hospice. Median duration of hospice was 3 (range 1-41) days. 72% had an advance directive on record and 37% were seen by palliative medicine. There was a higher rate of mechanical ventilation (p 1 intensive care indicators. Conclusions There is a high utilization of intensive care and procedures in the last days of life for patients dying in the hospital. Patients with advance directives were more likely to experience a value based EOL care including avoidance of intensive, and ultimately futile, medical care.