End-of-life trajectories of patients with haematological malignancies and advanced solid tumours 81 DISCUSSION This study gives insight into the disease trajectory of haematological malignancy (HM)- patients and in the differences compared to the disease trajectory of patients with a solid tumour (ST) visiting the ED in the last three months of their lives. Limitations on life-sustaining treatments (LST) were often not discussed in HM-patients before their ED-visit; and if these were discussed, patients often had no limitations on LSTs. Endof-life care was considerably more aggressive in HM-patients compared to ST-patients. HM-patients had a worse survival than ST patients, and more often died in-hospital and in the ICU and seldom in a hospice. Our results show that end-of-life care implicates aggressive in HM-patients: they scored poorly on five of the indicators of quality of end-of-life care by Earle.24 Our findings are in accordance with international literature reporting that HM-patients receive intensive treatments until death. In a study by Hui et al., HM-patients received significantly more chemotherapy (21%) and targeted therapy (17%) than ST-patients (6% and 5%, respectively).2 Other studies report that HM-patients often received G-CSF, blood transfusions and antibiotics and underwent diagnostic imaging, blood sampling, endoscopy and bone marrow examination in the last seven days of life.23,29 A French study in patients who died from metastatic lung cancer showed that end-of-life care was less aggressive the earlier palliative care needs were reported in their EPRs: patients sooner stopped anticancer treatment and they underwent less often invasive ventilation.30 In patients with pancreatic cancer in the last thirty days of life who were referred to a Table 4. Comparison of indicators of quality of end-of-life care between 78 patients with a haematological malignancy and 420 patients with a solid tumour. Indicators of quality of end-of-life care Total n=498 HM-patients n=78 ST-patients n=420 n (%) n (%) n (%) P-value Intensive anti-cancer treatmenta 375 (72.4) 59 (75.6) 316 (71.8) 0.48 Number of ED-visitsb, median (range) 1.00 (0-9) 1.00 (0-9) 1.00 (0-7) 0.12 In-hospital death 183 (35.3) 53 (67.9) 130 (29.5) <0.0001 Death in an acute hospital settingc 35 (6.8) 23 (29.5) 12 (2.7) <0.0001 Death in hospice 48 (9.2) 2 (2.6) 46 (10.5) 0.011 List of abbreviations: HM: haematological malignancy; ST: solid tumour; ED: emergency department; ICU: intensive care unit a Number of intensive anti-cancer treatments received in the 3 months before ED-visit. Intensive anti-cancer treatments included: chemotherapy, targeted therapy, stem cell transplantation, surgery, radiotherapy, hormonal therapy, nuclear therapy. b Number of ED-visits in 6 months before current ED-visit. c Acute hospital settings included the ED and the ICU. 4
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