End-of-Life Care Intensity in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation: A Population-Level Analysis

Abstract

Purpose: Intensity of end-of-life care receives much attention in oncology because of concerns that high-intensity care is inconsistent with patient goals, leads to worse caregiver outcomes, and is expensive. Little is known about such care in those undergoing allogeneic hematopoietic cell transplantation (HCT), a population at high risk for morbidity and mortality.

Patients and methods: We conducted a population-based analysis of patients who died between 2000 and 2013, within 1 year of undergoing an inpatient allogeneic HCT using California administrative data. Previously validated markers of intensity were examined and included: hospital death, intensive care unit (ICU) admission, and procedures such as intubation and cardiopulmonary resuscitation at end of life. Multivariable logistic regression models determined clinical and sociodemographic factors associated with: hospital death, a medically intense intervention (ICU admission, cardiopulmonary resuscitation, hemodialysis, intubation), and ≥ two intensity markers.

Results: Of the 2,135 patients in the study population, 377 were pediatric patients (age ≤ 21 years), 461 were young adults (age 22 to 39 years), and 1,297 were adults (age ≥ 40 years). The most common intensity markers were: hospital death (83%), ICU admission (49%), and intubation (45%). Medical intensity varied according to age, underlying diagnosis, and presence of comorbidities at time of HCT. Patients with higher-intensity end-of-life care included patients age 15 to 21 years and 30 to 59 years, patients with acute lymphoblastic leukemia, and those with comorbidities at time of HCT.

Conclusion: Patients dying within 1 year of inpatient allogeneic HCT are receiving medically intense end-of-life care with variations related to age, underlying diagnosis, and presence of comorbidities at time of HCT. Future studies need to determine if these patterns are consistent with patient and family goals.

Fig 1.

CONSORT diagram showing the study population. The study population included all patients who died between 2000 and 2013 in California and underwent an inpatient hematopoietic cell transplantation (HCT) within 1 year of death who did not die as a result of peripartum events or trauma (N = 2,135).

Fig 2.

Rates of intense end-of-life care by age category (overall, pediatric [age 0 to 21 years], adolescent and young adult [AYA; age 22 to 39 years], and adult [age ≥ 40 years]).

Fig A1.

Rates of intense end-of-life care by timing of death (during hematopoietic cell transplantation [HCT] admission or not) for the three primary outcomes: hospital death, receipt of a medically intense intervention, and presence of ≥ two intensity markers. The rates are broken down by age category (overall, pediatric, adolescent and young adult [AYA], and adult).