Tuesday, August 30, 2011

Pallative Care of Leukemia

alliative care for leukemia focuses on relieving symptoms, improving quality of life and supporting the patient throughout treatment for leukemia. Palliative care demands are different for different types of leukemia. For example, acute leukemia palliative care differs from chronic leukemia care. Palliative care is different from treatment designed to cure a disease. Instead, the goal of palliative care is to improve a patient's quality of life and relieve suffering by focusing on physical and emotional wellbeing.

Palliative Care vs. Hospice Care

Palliative care is often confused with hospice care, or end-of-life care. Hospice care includes palliative care by necessity, but palliative care alone doesn't mean that treatment for leukemia has failed. Instead, palliative care provides support in a number of areas, including:
  • Education
  • Emotional support
  • Pain management
  • Treatment complications.

Pain Management and Treatment for Leukemia

Leukemia can cause pain, including joint and bone pain due to accumulations of leukemia cells. Chronic leukemia may result in an enlarged spleen that places pressure on surrounding tissue, causing discomfort and pain. Infection of lymph nodes by leukemia cells can cause painful swelling.
Treatment for leukemia, including chemotherapy and radiation therapy, can also cause pain. In addition to treatment itself, causes of pain may include multiple needle sticks due to chemotherapy administration and blood sample and bone marrow collections.
Pain medication may be prescribed to manage leukemia pain. Pain caused by chemotherapy injection can be mitigated with central venous catheterization, a surgical procedure where a temporary catheter is inserted into a vein for administration of chemotherapy drugs.
Other strategies for managing leukemia pain may include:
  • Acupuncture
  • Counseling
  • Exercise therapy
  • Massage
  • Meditation
  • Relaxation or breathing techniques
  • Stress management techniques.

Prevention of Leukemia Treatment Problems

Prevention of treatment complications is an important part of palliative care for various types of leukemia. Chemotherapy and radiation therapy weaken the immune system, especially when given in the doses required for stem cell transplantation.
Prophylactic antibiotics may be provided to lower the risk of infection during treatment for leukemia. If necessary, antifungal and antiviral medications are employed. The patient may also receive nutritional advice from a dietician on how best to eat during leukemia treatment.

Emotional Support for Leukemia Patients

Acute leukemia symptoms develop rapidly, and chronic leukemia may not be detected until the disease is advanced. The transition from feeling healthy to facing a life-threatening illness is rapid and abrupt for many leukemia patients.
The emotional toll of leukemia on patients should not be understated. Palliative care may include counseling and support for both the patient and her family.

Patient Education and Palliative Care

Palliative care may also include educating the patient on his disease and offering suggestions on how to live with leukemia. Chronic lymphocytic leukemia, for instance, is often not treated in its early stages, unlike other types of leukemia. Instead, doctors typically recommend "watchful waiting," or monitoring the patient for chronic leukemia symptoms. Palliative care may include educating the patient on what signs to look for and report to medical professionals.


Once diagnosis is made, the goal of the leukemia team is to prevent complications such as bleeding, electrolyte abnormalities and infections that can potentially lead to death.
Biren Saraiya, MD
Biren Saraiya
Initially, the complications are due to the leukemia and later they are due to the chemotherapy. Usually the period of time patients spend in the hospital is in weeks. This long duration of the hospitalization allows the medical team, the patient and family to really get to know each other well.
The medical team’s focus is not only on the patient, but also on the family. Typically, patients are readmitted to the hospital for subsequent therapies as well, and again this potentially allows for a continued relationship between the medical team and the patient and family.
Though not formally called palliative care, the therapy typically involves prevention and treatment of complications. Antibacterial, antiviral and antifungal medications are used to prevent and treat infections; transfusions are used for the treatment of bone marrow dysfunction; and treatment with pain medications and parenteral nutrition for mucositis. Historically, the improvement in outcome of therapy has been due to these supportive measures as they have allowed for increasingly toxic therapy aimed at curing the cancer.
The traditional leukemia team typically includes physicians including the attending oncologist, house staff and consultants, but also nurses, a social worker, a physical therapist, a nutritionist and a pharmacist.
The traditional model of palliative care also involves a team of medical professionals including physicians, nurses, a social worker, a physical therapist, a nutritionist, a pharmacist, and a psychologist or psychiatrist.
Despite having similar goals and similar team members there is a disconnect. In my estimation, there are at least two factors for this disconnect. One is of perception. Many nonleukemia professionals (and in my case my house staff) have the perception that leukemia doctors push patients too hard (even give chemotherapy in the ICU!), while many leukemia doctors may feel that the patient population they serve, even the elderly, can benefit from very aggressive therapy. This may be related to the differences in potential outcomes. With leukemia, the other “c” word, cure, is possible even in the poor-risk group. In the case of a typical solid tumor patient, the goal of therapy becomes palliative in nature once the cancer is metastatic.
The other disconnect is of time — by the nature of the disease, all decisions for therapy are made in a very short amount of time as compared to other solid tumor malignancies. This obviously creates a situation where a patient who until very recently had been feeling well needs to make a decision regarding therapy in a relatively short period of time or they could potentially die. In my limited experience, that is not much of a choice.
Unlike patients with solid tumor malignancy where there is gradual onset of symptoms such as dyspnea, pain and decrease in performance status, leukemia may have a very acute onset.
In a 2001 editorial in Leukemia Research, Mary Laudon Thomas, MD, called for integration of both palliative care and leukemia therapy. And if one looks at the similarities between the two, it makes perfect sense. The outcomes for patients receiving the aggressive chemotherapy are improved with better symptom control. The primary team has many concerns to deal with besides the symptoms. We know from previous research that when there is a specific person or a team focused on symptoms, the symptom control is improved. Shouldn’t then it be standard of care to have a team member focused solely on patient’s symptoms?

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