Lisa Newton Bradford Teaching Hospitals NHS Foundation Trust

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  • Lisa Newton Bradford Teaching Hospitals NHS Foundation Trust
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  • Background information Blood product support Bleeding in cancer patients Case studies Myelodysplasia Prognostic factors in lymphoma and leukaemia
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  • Review by University of York, Palliative Medicine 2011 Haematological malignancy patients less likely to be referred to specialist palliative care services IOG recommends integration from time of diagnosis Current evidence doesnt support this Australian death in the curative system
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  • Do haematological malignancy patients have unmet needs? Are the needs met by others Haem CNS, Drs ? Haem malignancy patients more drowsiness and delirium and similar overall symptom severity to solid tumour patients Haem malignancy patients referred late (14 days prior to death v 47 days) Referral to palliative care more likely to have a home death generally preferred place? Haem patients 2 x as likely to die in hospital
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  • Is it the preferred place? Is it due specific factors: Diverse set of conditions with differing pathways for disease type eg MM years, elderly AML days Do the long term patients have appropriate symptom control /supportive care management from haematology team? But lots of trips to the wards, day unit prevents access to community palliative care which could reduce admissions for terminal care Absence of clear transition between curative, life prolonging and palliative phase of disease : Difficulty identifying the transition Timing of death unpredictable even for specific disease types Because nature of complications bleeding, sepsis may be rapid, variable number of therapies, variable response, unknown time to relapse, will it be the last relapse? efforts focussed on life saving treatment ICU deaths, young patients, Dr emotions, anecdotes
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  • Blood products Haemodialysis Iv vasopressors TPN Antibiotics Tube feeding Mechanical ventilation intravenous fluids
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  • In general prefer to withdraw forms that were scarce, expensive, invasive, unnatural, artificial, emotionally taxing for the patient, high technology and rapidly fatal when withdrawn Prefer not to withdraw forms that require continuous rather than intermittent administration, forms that cause pain when withdrawn Less likely to withdraw if supporting iatrogenic complication Preference for withdrawing a recently implemented support Timing of death prefer to withdraw treatment resulting in immediate death Physician social and professional charas no assoc with sex, religion (Catholic, Jewish less likely 1 study), rank, specialty Physician age more likely if younger Does a particular specialty feel more comfortable withdrawing its own form of life including haematologists
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  • LOW PLATELETS, PLATELET DYSFUNCTION, REDUCED CLOTTING FACTORS Chemotherapy (BM depression, DIC trigger) Radiotherapy DIC Sepsis Vitamin K deficiency BM infiltration (haematological, lung, thyroid, renal breast, prostate) Hypersplenism TTP ITP Liver dysfunction Mucosal bleeding, bruising
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  • Underlying disorder Systemic activation of coagulation Widespread fibrin deposition Consumption of platelets and clotting factors Microvascular thromboticlow platelets and obstructioncoagulation factors ORGAN FAILUREBLEEDING
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  • Red cells aim for Hb >8-9 (depends on symptoms, age, comorbidities Platelets if febrile transfuse if < 20 otherwise
  • Cytogenetics good 69%, standard 50%, poor 20% (33% with BMT) 5 years (60/
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  • Age 2-10,