Introduction

Patients presenting with hematologic malignancies experience multiple symptoms while also confronting the emotional distress of a newly diagnosed life-threatening illness. Most will notice reduced physical functioning prior to admission. Many will also note a change in their role within the family structure as they become more dependent because of the symptoms. Overall quality of life is significantly impaired compared to the age-matched normal population.1 Pain and fatigue will improve with successful treatment and approximate the normal population at 3 months. However, physical and role (social) functioning within the family remains substantially below premorbid levels despite successful ther-apy.1 Other symptoms at diagnoses include fever from infections, bleeding, and weight loss.2 Weight loss is particularly evident in patients with myeloma and amyloid or in individuals who have primary amyloidosis.3 Little is written about the presenting symptoms associated with acute leukemia. Some of the reported symptoms include fatigue, fever, bleeding, and pain. The pain from acute leukemia is more generalized than the pain that occurs with myeloma, and more frequently centered in the chest.4

Symptoms near the end of life for hematologic malignancies in general are protean. Dyspnea occurs due to cardiac insufficiency (perhaps from comorbidities, anthracycline toxicity, or radiation), fevers from infections, and hyperleukocytosis, which can cause neurologic deficits and hypoxemia. Lymphangitic tumor infiltration with pain and shortness of breath, pulmonary fibrosis, mediastinal adenopathy with atelectasis, pleural effusion, and growing tumor masses add to dyspnea, pain, and debility.5 Fevers occur in 40% of acute leukemia patients near the end of life. Severe pain is present in 27%. Abdominal pain is present in 60%, bone pain in 30%, and thoracic pain in 10%.5 Clinical evidence of bleeding occurs in 20%, excluding ecchymosis and petechiae. Delirium will be present in at least 25%, with the incidence steadily rising as death approaches. Mucositis will be a major problem in 9%.5

Chemotherapy will be given to 46% as palliation in the terminal phase, either for hyperleukocytosis or painful compressive lymphadenopathy. Many will receive short courses of radiation for the same reason. Antibiotics will be prescribed in nearly half. Blood transfusions, particularly red blood cells, will be given to 40% in the terminal phase of their illness.5 Patients will be on opioids (27% of patients), steroids (40%), and benzodiazepines (90%), all of which will be necessary to palliate symptoms but will also increase the risk of delirium. A Do Not Resuscitate (DNR) order will be written in only 38% despite the fact that deaths are anticipated in nearly 80%.5

Many patients with acute leukemia in the terminal phase will have clinically evident (wet) bleeding (44%), fever with infections (71%), and bone pain (76%).4 One quarter will have oral pain and dysphagia and over one-third of patients will have problems with nausea and vomiting.4 Such symptoms will preclude oral opi-oids for pain control. Many patients will have central lines for parenteral infusion, while a minority without venous access will be given subcutaneous opioids.4 Rectal administration of medications, commonly used in hospice, is avoided because of the risk of infections and bleeding. As a result, the versatility of palliative medications is limited by the disease process.

Unadjusted survival for leukemia and lymphoma patients entering hospice programs is much shorter than that for the patients with solid tumors. In 1996, the median survival for patients with hematologic malignancies after hospice enrollment was 23 days, and 20% died within 7 days.6

Patients with hematologic malignancies have a greater chance of dying within the hospital compared to patients with solid tumors7. In South Australia, all leukemia patients died in the hospital and few received palliative consults for managing symptoms at the end of life.7 On average, the risk of dying within a hospital is four times that of solid tumor patients. Patients with hematologic malignancies have the lowest enrollment in hospice programs per disease category.8 This may in part be because of the reluctance of hospice programs to administer blood transfusions, a treatment considered palliative by most physicians specializing in the hematologic malignancies.

Free Yourself from Panic Attacks

Free Yourself from Panic Attacks

With all the stresses and strains of modern living, panic attacks are become a common problem for many people. Panic attacks occur when the pressure we are living under starts to creep up and overwhelm us. Often it's a result of running on the treadmill of life and forgetting to watch the signs and symptoms of the effects of excessive stress on our bodies. Thankfully panic attacks are very treatable. Often it is just a matter of learning to recognize the symptoms and learn simple but effective techniques that help you release yourself from the crippling effects a panic attack can bring.

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