Friday, June 8

EHA / ESH JOINT SYMPOSIUM

11.15-12.30 hours, Room: Stolz I

GREAT EXPECTATIONS: WHEN RELATIVES WANT EVERYTHING DONE

An interactive session for hematologists.

The use of high-risk treatment strategies such as allogeneic stem-cell transplantation is relatively common in hematological practice. Inevitably, events do not always proceed smoothly and the management of critically ill patients is a problem that clinicians working in this field must frequently face. The medical challenges involved in treating profoundly immunosuppressed patients with evolving major organ failure are very considerable and in many institutions the clinical facilities of an Intensive Care Unit will be needed to deliver ventilatory or renal support. Patients and their families must therefore be prepared for transfer from the Hematology Unit to a new and unfamiliar environment within the hospital. The clinical prognosis of patients in this setting is generally poor and the risk of death for neutropenic patients requiring intensive care support is even greater than that of patients with preserved immunity.

While it is necessary and appropriate to counsel the patient and family honestly about the seriousness of the situation before undertaking a transfer to intensive care, it is not always easy to explain the limitations of clinical care. Although patients may well have been through a thorough consent procedure before undergoing their transplant, they seldom really acknowledge that the risks of morbidity or mortality might apply to them as individuals. The act of submitting to a complex procedure such as allogeneic transplantation may also create an air of confidence in the expertise of the medical attendants that will translate into a belief that anything can be achieved. Subsequently, when problems arise it may be difficult to convince the patient and their relatives that the prognosis is now very poor and the chances of survival are low.

Once the patient has been accepted and transferred to an Intensive Care Unit they are frequently in a condition where their own views can no longer be taken into account. This places the relatives in an important role in the subsequent discussions about treatment choices and may ultimately lead to their involvement in the consideration of treatment withdrawal. Communication with the patient’s relatives is crucial under these circumstances and will need to be of a very high standard throughout. It is desirable that despite the urgency of the clinical situation, a full discussion is undertaken at the time of transfer to the Intensive Care Unit. This should be continued through treatment with frequent access to nursing and medical staff and continued input from the hematology team so that families do not feel that they have been abandoned. If a decision to withdraw support becomes clinically inevitable, a conference with the family is a most important part of the process and if handled sensitively may ease the transition to bereavement and satisfy relatives that ‘everything possible has been done’.

FACULTY

S. Johnson (Taunton, United Kingdom)
G. Jackson (Newcastle, United Kingdom)
K. England (Birmingham, United Kingdom)

PROGRAM

AIM OF MEETING/RULES OF ENGAGEMENT
Steve Johnson

CASE STUDY

The patient is a 45 year-old man with poor risk Acute Myeloid Leukemia who underwent a reduced intensity allogeneic stem-cell transplant from his brother. He is not engrafted at day +12 but has had worsening respiratory function for the last 24 hours. A broncho-alveolar lavage has produced no organisms. He is now desaturating despite C-PAP on the hematology unit and is beginning to show evidence of deteriorating renal and hepatic function. The patient is too unwell to engage in any discussion about his management and his wife and brother are on the unit to talk about transfer to intensive care.

CLINICAL CONSULTATION

G. Jackson (Newcastle, United Kingdom)

DISCUSSION AND FEEDBACK

S. Johnson (Taunton, United Kingdom)

LESSONS FOR CLINICAL PRACTICE

K. England (Birmingham, United Kingdom)

CONCLUSIONS

S. Johnson (Taunton, United Kingdom)

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