Preferences for Palliative and End-of-Life Care: A Systematic Review of Discrete Choice Experiments.

OBJECTIVES: Understanding what matters most to patients and their caregivers is fundamental to delivering high-quality care. This systematic review aimed to characterize and appraise the evidence from discrete choice experiments eliciting preferences for palliative care. METHODS: A systematic literature search was undertaken for publications up until August 2022. Data were synthesized narratively. Thematic analysis was applied to categorize attributes into groups. Attribute development, frequency, and relative importance were analyzed. Subgroup analyses were conducted to compare outcomes between patient and proxy respondents. RESULTS: Seventeen studies spanning 11 countries were included; 59% of studies solely considered preferences for patients with cancer. A range of respondent groups were represented including patients (76%) and proxies (caregivers [35%], health providers [12%], and the public [18%]). A total of 117 individual attributes were extracted and thematically grouped into 8 broad categories and 21 subcategories. Clinical outcomes including quality of life, length of life, and pain control were the most frequently reported attributes, whereas attributes relating to psychosocial components were largely absent. Both patients and proxy respondents prioritized pain control over additional survival time. Nevertheless, there were differences between respondent cohorts in the emphasis on other attributes such as access to care, timely information, and low risk of adverse effects (prioritized by patients), as opposed to cost, quality, and delivery of care (prioritized by proxies). CONCLUSIONS: Our review underscores the vital role of pain control in palliative care; in addition, it shed light on the complexity and relative strength of preferences for various aspects of care from multiple perspectives, which is useful in developing personalized, patient-centered models of care for individuals nearing the end of life.

Perspectives of inpatients with palliative care needs, their families, clinicians and key stakeholders on measuring quality of hospital care via patient experience measures: A qualitative study.

BACKGROUND: Globally there are high numbers of patients with palliative care needs receiving care in hospitals. Patient reported experience measures (PREMs) provide useful data to guide improvement work. How to implement PREMs within palliative care populations is unclear. AIM: To explore the perspectives of inpatients with palliative care needs, their family members, and the clinical team regarding the use of a generic PREM as compared with a PREM designed for people with palliative care needs and related implementation factors. DESIGN: A qualitative study was undertaken using semi-structured interviews and focus groups and integrated thematic analysis. SETTING/PARTICIPANTS: Inpatients with palliative care needs, their family members, and clinical team members were recruited from three wards in an Australian metropolitan hospital. RESULTS: Twenty-seven interviews and three focus groups were conducted. Six themes emerged: (1) PREMs for people with palliative care needs ought to be tailored to the needs of this population; (2) PREMs should appraise whether the needs of families have been met in addition to those of patients; (3) PREMs for inpatients with palliative care needs ought to be easy to use, brief and incorporate space for free text alongside each question; (4) Implementation of PREMs for people with palliative care needs ought to consider who administers these, when and how often; (5) PREM data need to be specific enough to inform process change and/or care provision; (6) Patients and families require meaningful feedback to encourage PREM completion. CONCLUSIONS: This study provides practical guidance for PREM selection and implementation to inform improvements to care for inpatients with palliative care needs.

Harnessing the power of clinician judgement. Identifying risk of deteriorating and dying in people with a haematological malignancy: A Delphi study.

AIM: To provide expert consensus on the clinical indicators that signal a person with a haematological malignancy is at high risk of deteriorating and dying. BACKGROUND: Identification of people who are at risk of deteriorating and dying is essential to facilitate patient autonomy, appropriate treatment decisions, and effective end-of-life care. DESIGN: A three-step modified Delphi approach. METHODS: The study was conducted over 6 months (September 2015-March 2016) to gather opinion from an international panel of experts (N = 27) on the clinical indicators that signal a person with a haematological malignancy is at high risk of deteriorating and dying. The first round was informed by a systematic review of prognostic factors present in the final months of life for people with a haematological malignancy. Consensus was achieved if 70% of responses fell within two points on a seven-point Likert-type scale. FINDINGS: Consensus was achieved on the following 11 clinical indicators: (a) advancing age; (b) declining performances status; (c) presence of co-morbidities; (d) disease status; (e) persistent infections (bacterial and viral); (f) fungal infections; (g) severe graft versus host disease; (h) requiring high care; (i) signs of frailty; (j) treatment limitations; and (k) anorexia and/or weight loss. Consensus was also achieved on associated themes and statements for each indicator. CONCLUSION: The findings of this study indicate that subjective clinician-assessed indicators that are contextually relevant to the nature of haematological malignancies are markers of risk. This study has provided valuable preliminary findings on the topic and will inform future research.

Nurses attitudes and practices towards provision of survivorship care for people with a haematological cancer on completion of treatment.

PURPOSE: The purpose of this study is to assess cancer nurses' perceptions of responsibility, confidence levels and practice in relation to survivorship care for people with a haematological malignancy on completion of treatment. METHODS: A prospective cross-sectional survey was conducted. An online survey was distributed to members of two Australian professional bodies. RESULTS: A total of 310 cancer nurses participated in the study, representing a response rate of 28%. The participants generally agreed that all survivorship care items were part of their role. Of the 17 survivorship care items, the three items receiving the lowest confidence scores were discussing fertility issues, discussing employment and financial issues and discussing how to identify signs of cancer recurrence. The least performed survivorship care items were discussing fertility issues, communicating survivorship care with primary healthcare team (i.e. general practitioners) and discussing sexuality issues. Older age, more years of experience, having a post-graduate qualification and working in non-metropolitan area were associated with higher levels of perception of responsibilities and confidence (p < 0.05). The top ranked barriers to survivorship care were reported to be lack of end-of-treatment consultation dedicated to survivorship care, time and an appropriate physical space for delivering care. CONCLUSIONS: Cancer nurses perceive key aspects of survivorship care to be part of their role, however there remains variations in practice and confidence with respect to implementation of survivorship care practices. IMPLICATIONS FOR CANCER SURVIVORS: Interventions that focus on enhancing the capability of cancer nurses and eliminating barriers identified in this study have the potential to improve quality survivorship care provision.

A systematic review of prognostic factors at the end of life for people with a hematological malignancy.

BACKGROUND: Accurate prognosticating is needed when patients are nearing the end of life to ensure appropriate treatment decisions, and facilitate palliative care provision and transitioning to terminal care. People with a hematological malignancy characteristically experience a fluctuating illness trajectory leading to difficulties with prognosticating. The aim of this review was to identify current knowledge regarding 'bedside' prognostic factors in the final 3 months of life for people with a hematological malignancy associated with increased risk of mortality. METHODS: A systematic review of the literature was performed across: PubMed; CINAHL; PsycINFO; and Cochrane with set inclusion criteria: 1) prognostic cohort studies; 2) published 2004-2014; 3) sample ≥ 18 years; 4) >50% sample had a hematological malignancy; 5) reported 'bedside' prognostic factors; 6) median survival of <3 months; and 7) English language. Quality appraisal was performed using the Quality In Prognostic Studies (QUIPS) tool. Results are reported in line with PRISMA guidelines. RESULTS: The search returned 4860 studies of which 28 met inclusion criteria. Twenty-four studies were rated moderate quality, three were high quality and one study was deemed to be of low quality. Most studies were set in the ICU (n = 24/28) and were retrospective (n = 25/28). Forty 'bedside' prognostic factors were identified as associated with increased risk of mortality encompassing the following broad categories: 1) demographics; 2) physiological complications or conditions; 3) disease characteristics; 4) laboratory blood values; and 5) interventions. CONCLUSIONS: The literature on prognosticating in the final months of life was predominantly focused on people who had experienced acute physiological deterioration and were being treated aggressively in the in-patient setting. A significant gap in the literature exists for people who are treated less aggressively or are on a palliative trajectory. Findings did not report on, or confirm the significance of, many of the key prognostic factors associated with increased risk of mortality at the end of life in the solid tumour population, demonstrating key differences in the two populations. TRIAL REGISTRATION: This systematic review was not registered.

Clinical research nursing pathways: The development and evaluation of a nursing research internship program using the RE-AIM framework.

Background: In 2018 a Nursing Research Internship program was started within a major referral and tertiary teaching centre in Australia. Aim: We aimed to evaluate the first 12 months of the program using an implementation science framework. Methods: This was a qualitative study. Following ethical approval n = 20 semi -structured interviews were recorded and transcribed verbatim. Participants included nurses with clinical, research and management roles who had engaged in or supported a Nursing Research Internship program. The Framework Method was conducted to analyse the findings. Results: Key themes identified included 'What is the impact of a Nursing Research Internship program?'; 'Why do a Nursing Research Internship program?'; 'How do we do a Nursing Research Internship program?'; 'How do we sustain a Nursing Research Internship program?'. Positive impacts were identified for clinical nurses and their teams, for the hospital and health service, and for patients and families. Identified key components included protected research time, specialist support (including library, statistics, health economist, implementation scientist), regulatory support (ethics and governance procedures) and access to a computer and IT resources. The Nursing Research Internship program required support from nurse clinicians, nurse managers and nurse academics. Conclusion: A structured Nursing Research Internship program supports clinical nurses to answer research questions identified directly from clinical practice.

Supporting Cancer Survivors Following Treatment for Non-Hodgkin's and Hodgkin's Lymphoma: A Pilot Study Assessing the Feasibility and Process Outcomes of a Nurse-Led Intervention.

OBJECTIVE: Lymphoma is the sixth most common cancer in Australia and comprises 2.8% of worldwide cancer diagnoses. Research targeting development and evaluation of post-treatment care for debilitating complications resulting from the disease and its treatment is limited. This study aimed to assess the feasibility and acceptability of a nurse-led survivorship intervention, post-treatment in Hodgkin's and non-Hodgkin's lymphoma survivors. METHODS: A single-center, prospective, 3-arm, pilot, randomized controlled, parallel-group trial was used. People with lymphoma were recruited and randomized to the intervention (ENGAGE), education booklet only, or usual care arm. Participants receiving ENGAGE received an educational booklet and were offered 3 consultations (via various modes) with a cancer nurse to develop a survivorship care plan and healthcare goals. Participant distress and intervention acceptability was measured at baseline and 12-wk. Acceptability was measured via a satisfaction survey using a 11-point scale. Feasibility was measured using participation, retention rates, and process outcomes. Data were analyzed using descriptive statistics. RESULTS: Thirty-four participants with HL and NHL were recruited to the study (11 = intervention, 11 = information only, 12 = usual care). Twenty-seven participants (79%) completed all time points from baseline to 12 wk. Seven (88%) of the 8 participants receiving ENGAGE completed all consultations using various modes to communicate with the nurse (videoconference 14/23, 61%; phone 5/23, 22%; face-to-face 4/23, 17%). Participants who completed the intervention were highly satisfied with ENGAGE. CONCLUSION: The ENGAGE intervention is feasible and highly acceptable for lymphoma survivors. These findings will inform a larger trial assessing effectiveness and cost effectiveness of ENGAGE.

Addressing the end-of-life actions in the National Safety and Quality Health Service Standards (2nd edn): a national survey.

Objectives To describe current and planned processes and outcome measures to address implementation of the six end-of-life actions in the National Safety and Quality Health Service (NSQHS) Standards (2nd edn) and explore associated barriers and enablers. Methods This study used an exploratory mixed methods national survey of acute healthcare facilities between September 2018 and March 2019. This study involved public and private facilities (N = 765) that provided end-of-life care, which are required to be accredited to the NSQHS Standards. Participants include those responsible for reporting implementation of end-of-life care actions at a facility providing end-of-life care. Participants were asked what processes and outcome measures were implemented or being planned to address the end-of-life care actions, and the associated barriers and enablers. Results Fifty respondents (6.5% response rate) from across Australia contributed data, reporting greater confidence in addressing Actions 5.16: Clinicians have access to Specialist Palliative Care Services; 5.17: Advance care plans can be received from patients and stored in medical records; and 5.18: Supervision and support is available for workforce providing end-of-life care. Barriers associated with the actions that were the most challenging to address included: competing clinical priorities, and insufficient resources to provide best practice end-of-life care; and the burdensome nature of conducting audits. Enablers included: (1) local, jurisdictional, and national strategic plans and policies; (2) support from Specialist Palliative Care Services; (3) access to resources and data; (4) standardised approaches to implementation and measuring outcomes; and (5) clinician, consumer and community engagement and education on end-of-life care. Conclusion Enablers and barriers in implementing the six end-of-life care actions were identified. Respondents reported that high-level support and direction, system-wide approaches, practical clinical support, and widespread community and clinician engagement would enable their facility to better address the end-of-life actions.

Clinicians' Understanding of Preferences and Values of People with Hematological Malignancies at the End of Life: Concurrent Surveys.

Background: People with hematological malignancies can deteriorate rapidly to a terminal event and have variable levels of engagement when transitioning to palliative and end-of-life care. Objectives: To describe end-of-life care values and preferences of people with hematological malignancies and explore whether these align with hematology clinicians' perceptions. Design: Two matched anonymous quantitative cross-sectional surveys explored: (1) patients' values and preferences around manner and timing of discussions regarding life expectancy and prognosis, involvement in decision making, and concurrent integration of palliative care with active treatment; and (2) clinicians' perceptions of their patients' values and preferences in relation to prognostic information. Settings/Participants: Concurrent online national surveys of people with hematological malignancies known to the Leukemia Foundation of Australia, and clinicians in Australia with membership to the Hematology Society of Australia and New Zealand. Results: Five hundred nine (38% response rate) patients (median age 64 [min 20, max 89, interquartile range 56-70]) and 272 clinicians (21% response rate) responded to the survey. If their health was deteriorating, most patients wanted honest prognostic and life expectancy information (87%); welcomed involvement in decision making (94%); felt they would be comfortable talking to the treating team about the possibility of death (86%); and would be comfortable seeing someone from a specialist palliative care team (74%). Clinicians generally underestimated most of these responses. Conclusion: Although our findings indicate that most people believe they would be comfortable discussing prognosis, life expectancy, and wishes at the end of life, clinicians were largely unaware of their preferences. This highlights the need to embed values clarification in routine care for each patient and family.

Prospective cohort study of an Australian cancer care services-led model of emergent care.

ObjectiveMany cancer care services (CCS) provide pragmatic models of emergent care for their patients as part of 'business as usual' without understanding the scope of this work. We aimed to describe an Australian CCS-led model of emergent care and quantify and profile emergent care provided over a 6-month period to understand scope and demand.MethodsThis prospective cohort study was performed at a large tertiary hospital on the eastern coast of Australia in 2016. The study explored emergent care provided during business hour and after-hours, including telephone advice, unplanned care and unplanned admissions. Data were collected via electronic hospital records and clinical nurses regarding who accessed care, why care was accessed, what care was provided and how the episode of care ended.ResultsBetween March and September 2016, 1412 episodes of unplanned care were provided in the CCS-led model of care, including 307 episodes of telephone advice (237 patients; min max 1-4 episodes per patient; 825 episodes of unplanned care (484 patients; min max 1-9 episodes per patient) and 280 unplanned admissions (233 patients; min max 1-6 episodes per patient). During the same time, an additional 459 unplanned admissions (361 patients) occurred via the emergency department (ED), of which 125 (27.2%) occurred during business hours which could have been managed by the CCS. Most people who received care experienced issues associated with disease or treatment and had received systemic anticancer therapy in the past 30 days.ConclusionsThe data demonstrate that a significant volume of emergent care was provided within the CCS over the study period, in addition to planned cancer treatment. Due to the ever-increasing demands on EDs and the significant need for emergent care for people with cancer, there is need for CCS-led models of care to provide specialist emergent care specifically for people who are receiving systemic anticancer therapy. Such models must be adequately resourced to meet the needs of patients, carers and healthcare professionals.What is known about the topic?There is increasing focus on innovative models of emergent care for people with cancer in the out-patient setting to relieve pressure on EDs and improve patient experiences. Limited literature has focused on such models in the Australian context.What does this paper add?This paper describes, quantifies and profiles care provided in a pragmatic CCS-led model of emergent care in a large tertiary hospital in Australia over 6 months. The data demonstrate significant demand for emergent care within business hours, as well as out of hours, predominantly for people undergoing systemic anticancer therapy.What are the implications for practitioners?The findings of this study highlight the need for CCS to develop pragmatic models of emergent care. Appropriate resources, infrastructure, policies and procedures are required to adequate meet the needs of patients and carers.

Skin and wound care for individuals with graft versus host disease: a scoping review protocol.

INTRODUCTION: Graft versus host disease (GVHD) is a major cause of morbidity and mortality following allogenic haematopoietic stem cell transplantation. It is an immunological reaction, involving many organs, leading to a wide range of clinical manifestations. Cutaneous manifestations are the most common sign of GVHD, as well as pain, vulnerability to infection and impaired quality of life.Despite the burdens that cutaneous GVHD presents for patients, their carers and the healthcare system, limited evidence is available to guide day to day supportive skin care and wound management. Our objective is to conduct a scoping review to map the evidence for skin and wound management and identify evidence-practice gaps for individuals with acute or chronic cutaneous GVHD. METHODS AND ANALYSIS: Our review will follow the scoping review methodological framework developed by Arksey and O'Malley and further refined by the Joanna Briggs Institute Scoping Review Methods Manual. Databases to be searched include; PubMed, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Web of Science and MEDLINE from 1970 to February 2020. Database searches will be supplemented with searches from relevant reference lists and grey literature. Descriptive statistical analyses will be performed. ETHICS AND DISSEMINATION: This scoping review does not require ethical approval. Findings will be disseminated through a peer-reviewed publication and conference presentation.

How do cancer care services in Australia take care of their patients when they require emergency care? We need more evidence.

A letter to the editor on cancer patients accessing emergency care.

Taking care of our own: A narrative review of cancer care services-led models of care providing emergent care to patients with cancer.

PURPOSE: To synthesise available evidence on cancer care services-led models of care in the acute care setting that aim to reduce emergency presentations and/or hospital admissions for patients with cancer. METHODS: A narrative review of studies describing models of care for patients with cancer and emergent healthcare needs was undertaken. Four databases were searched using keywords to identify primary research or quality improvement articles published between January 2005-June 2017. RESULTS: After a systematic search, 22 studies were included in the review. The methodological quality of the included studies was poor when assessed using the Mixed Methods Appraisal Tool. Most studies were retrospective and set in a single centre. The overarching outcomes associated with the most commonly described models of care (telephone advice services and/or unplanned care and assessment units) were improved coordination of care/continuity of care, prompt access to specialist care, reduced utilisation of emergency departments, fewer hospital admissions and reduced cost. At the time of this review, evaluation of Nurse Practitioner-led services and acute oncology services had been limited. CONCLUSIONS: Findings indicate several models of care reduce emergency presentations and/or hospitalisations for those living with cancer and improve patient outcomes. What remains unclear is which underlying mechanisms reduce emergency presentations and/or hospitalisations for patients with cancer and whether successful models of care are uniquely suited to specific contexts of care or applicable across different healthcare settings. More research is needed to assist healthcare services to develop and evaluate models of care to address the emergent needs of people with cancer.

A single-blind, randomised controlled trial of StrataXRT® - A silicone-based film-forming gel dressing for prophylaxis and management of radiation dermatitis in patients with head and neck cancer.

AIM: Investigate the effects of StrataXRT® versus 10% Glycerine (Sorbolene cream) for preventing and managing radiation dermatitis in patients with head and neck cancer receiving radical radiotherapy (≥50 Gy) with or without chemotherapy or biotherapy. METHODS: A single-blind, randomised controlled, superiority trial was conducted. Patients either received StrataXRT® or Sorbolene (usual care). Skin toxicity, pain, itching and skin-related quality of life scores were collected from baseline, and up to four weeks post-treatment. RESULTS: A total of 197 patients were randomised into the study. Skin toxicity was dependent on the treatment group with StrataXRT® patients experiencing lower mean skin toxicity at the end of the radiation treatment (P = 0.002). At the end of treatment, the StrataXRT® arm had a lower percentage of grade 2 (80%) and grade 3 (28%) skin toxicity compared to the sorbolene arm (91% and 45% respectively). After adjustment for Cetuximab, the StrataXRT® arm had a 12% lower risk of experiencing grade 2 skin toxicity (RRR = 0.876, 95% CI: 0.778-0.987, P = 0.031); and a 36% lower risk of experiencing grade 3 skin toxicity (RRR = 0.648, 95% CI: 0.442-0.947, P = 0.025). Cox regression analysis showed that patients receiving StrataXRT® had a 41.0% and 49.4% reduced risks of developing grade 2 and 3 skin toxicity respectively throughout treatment compared to the Sorbolene arm. There were no differences between groups in patient-reported outcomes. No treatment interruptions and study product related adverse events were reported in either arm. CONCLUSION: StrataXRT® is effective for preventing, and delaying the development of grade 2 and 3 skin toxicity. TRIAL REGISTRATION: ACTRN12616000511437.

Clinical Indicators That Identify Risk of Deteriorating and Dying in People with a Hematological Malignancy: A Case-Control Study with Multivariable Analysis.

BACKGROUND: Identifying people who are at risk of deteriorating and dying is essential to inform goals of care, appropriate treatment decisions, patient autonomy, and effective end-of-life care. Limited literature exists on predicting survival near the end of life for people with a hematological malignancy. OBJECTIVE: To identify the key clinical indicators that signal a person with a hematological malignancy is at high risk of deteriorating and dying. DESIGN, SETTING, PARTICIPANTS: Eleven clinical indicators identified in a Delphi approach were tested via a retrospective case-control study. Each indicator was assessed for at each in-patient admission between living (n = 236) and deceased (n = 120) people with a hematological malignancy who were admitted to a large tertiary hospital between 1st July 2014 and 31st December 2015. RESULTS: Six clinical indicators were independently associated with mortality in the final three months of life: declining performance status (Odds Ratio [OR] 7.153, 95% Confidence Intervals [CI] 3.281-15.597, p = < 0.001); treatment limitations of the hematological malignancy (OR 7.855, 95% CI 3.528-17.489, p = < 0.001); relapse, refractory or persistent disease (OR 3.749, 95% CI 1.749-8.039, p = 0.001); presence of two or more comorbidities (OR 2.991, 95% CI 1.319-6.781, p = 0.009); invasive fungal infections (OR 4.887, 95% CI 1.197-19.949, p = 0.027); and persistent infections (OR 6.072, 95% CI 2.551-14.457, p = < 0.001). CONCLUSIONS: This study has identified six clinical indicators that signal a person with a hematological malignancy is at high risk of deteriorating and dying and may benefit from an assessment of palliative needs and proactive planning, along-side appropriate treatment.

Does a Dedicated Lumen for Parenteral Nutrition Administration Reduce the Risk of Catheter-Related Bloodstream Infections? A Systematic Literature Review.

Guidelines recommend using single-lumen central vascular access devices (CVADs) for the administration of parenteral nutrition (PN) or lipid-based solutions, or a dedicated lumen on a multilumen CVAD. Publications reviewed by the authors reported comparative rates of catheter-related bloodstream infection (CR-BSI) in patients with CVADs who received PN through a dedicated lumen compared with those who had PN administered through multilumen CVADs. Two studies included 650 patients with 1349 CVADs. CR-BSIs were equally distributed between the 2 groups. Both studies were poorly reported and had significant risk of bias. These results should be interpreted with caution.

Does Parenteral Nutrition Increase the Risk of Catheter-Related Bloodstream Infection? A Systematic Literature Review.

BACKGROUND: Central venous access devices (CVADs) are used for parenteral nutrition (PN) delivery. We systematically reviewed research-based publications that reported comparative rates of catheter-related bloodstream infection (CRBSI) in patients with CVADs who received PN vs those who did not receive PN therapy. MATERIALS AND METHODS: The literature search included the Cochrane Library, MEDLINE, CINAHL, and PubMed up to July 14, 2015, to identity studies that compared patients with a CVAD who did and did not have PN therapy. RESULTS: Eleven observational studies were identified, comprising 2854 participants with 6287 CVADs. Six studies produced significant results in favor of non-PN, 4 studies showed no evidence of a difference between PN and non-PN, and 1 study produced significant results in favor of PN when analyzed per patient with multiple CVADs. Incidence ranged from 0 to 6.6 CRBSIs per 1000 CVAD days in the PN patients and 0.39 to 3.6 CRBSIs per 1000 CVAD days in the non-PN patients. The Cochrane risk of bias assessment tool for nonrandomized studies of interventions was used. Eight studies were rated as moderate risk of bias, 2 as serious, and 1 as critical. CONCLUSION: The data presented in this systematic review are not sufficient to establish whether patients receiving PN are more at risk of developing CRBSI than those who do not. Future PN studies needs to adjust for baseline imbalances and improve quality and reporting.

Signs, Symptoms, and Characteristics Associated With End of Life in People With a Hematologic Malignancy: A Review of the Literature.

PROBLEM IDENTIFICATION: Identifying people with hematologic cancer who are at risk of deteriorating and dying is essential to enable open, honest discussions, leading to appropriate decision making and effective end-of-life care.
. LITERATURE SEARCH: PubMed, CINAHL®, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 2005 to December 2015 for descriptive observational studies.
. DATA EVALUATION: Critique of the studies was guided by the Critical Appraisal Skills Programme Cohort Study Checklist.
. SYNTHESIS: Twelve studies were included. The majority of studies (n = 8) sampled patients from palliative populations, and most were retrospective (n = 11). A number of signs, symptoms, and characteristics associated with end of life in people with a hematolgic malignancy were identified, including pain, hematopoietic dysfunction, dyspnea, and reduced oral intake.
. CONCLUSIONS: The studies described a clinical scenario of deterioration, largely in a palliative population. Findings indicate that people with a hematologic malignancy share certain clinical signs of deterioration with other populations and receive a high level of medical interventions at the end of life.
. IMPLICATIONS FOR PRACTICE: Nurses are well positioned to identify many of the signs, symptoms, and characteristics found in this review and can play a key role in identifying when a person is nearing the end of life.