Integrating compassion early: palliative care’s role in improving the quality of life and psychological well-being for individuals undergoing hematopoietic stem cell transplantation

“The significance—and ultimately the quality—of the work we do is determined by our understanding of the story in which we are taking part.”

―Wendell Berry

Hematopoietic stem cell transplantation (HSCT) is one of the most intensive and potentially curative treatments in oncology (1-3). However, it is also one of the most physically and psychologically demanding experiences for patients and their caregivers in cancer care (4,5). Transplantation, whether autologous or allogeneic, requires lengthy hospital stays and clinic visits, involves uncertainty, and can significantly affect physical function and emotional well-being. Palliative care integration is inconsistent across transplant centers, often reserved for end-of-life situations rather than integrated into supportive services despite compelling evidence of its benefit. A notable gap remains (6,7).

Recent research by El-Jawahri et al., published in Journal of Clinical Oncology (8), has addressed this gap with a landmark multisite randomized controlled trial across three United States academic institutions. These findings highlight that palliative care, when initiated early and delivered systematically, can significantly improve the overall patient and caregiver experience of transplantation.

The trial involved 360 adults who underwent autologous or allogeneic HSCT between October 2018 and July 2022. No screening occurred between March 2020 and July 2020 because of the coronavirus disease (COVID-19) pandemic. Participants were assigned to either a twice-weekly inpatient palliative care intervention or usual care. They were stratified by study site and transplant type (autologous or allogeneic) to account for differences in recovery patterns after transplantation, thereby ensuring balanced, representative groups. The palliative care consultations focused on symptom management, coping, and psychosocial support, while patients in usual care could access palliative care through standard referral. Participants in the palliative care intervention met with either an inpatient palliative care physician or an advanced practice provider within 72 hours of randomization. Patient outcomes were measured at baseline, week 2, and at 3, 6, and 12 months post-HSCT using several validated tools: the Functional Assessment of Cancer Therapy-Bone Marrow Transplant for quality of life (QOL), the Hospital Anxiety and Depression Scale (HADS), and the post-traumatic stress disorder (PTSD) checklist. Caregivers completed the Caregiver-Oncology QOL measure at the same timepoints. The primary endpoint was patient quality of life at week 2—the period typically associated with the lowest level of physical and emotional distress during HSCT hospitalization. Data collected at 12 months after HSCT were not reported due to high dropout rates.

The findings were compelling, especially regarding the impact on QOL, depression, and PTSD symptoms at week 2. The 2-week improvement reflects the multicomponent intervention, which integrates pharmacologic and psychosocial components. The investigators demonstrated that integrating compassion early in a structured inpatient palliative care consultation during HSCT significantly improved patient QOL and reduced symptoms of depression and PTSD. Longitudinal analysis showed that palliative care recipients experienced a sharper decline in PTSD symptoms over 6 months post-transplant (P=0.01). Although anxiety and caregiver QOL did not show significant differences between groups, the overall effect on patient well-being was both clinically and statistically significant.

This study highlights the importance of evaluating this in HSCT by demonstrating that palliative care can be scaled across different institutional cultures and teams. An important aspect is the lasting effect on PTSD symptoms, which are often overlooked in transplant survivorship research (7,9). HSCT can be a traumatic experience due to physical deconditioning and fear of complications that may leave lasting psychological effects. The reduction in PTSD symptoms at 6 months indicates that early palliative care not only eases immediate suffering but also promotes long-term psychological recovery. This shifts the perception of palliative care from just symptom management to a tool for fostering psychological resilience during transplantation.

The observed improvements likely resulted from several interconnected factors. First, structured palliative care visits offered proactive symptom management and monitoring—addressing fatigue, pain, nausea, and sleep disturbances before they intensified. By easing these physical stressors, this approach may have helped reduce patients’ emotional distress and supported them in coping with treatment (10,11). Second, palliative care clinicians helped them understand their emotional responses differently, acknowledging fear, sadness, and uncertainty as natural aspects of the transplant experience rather than signs of pathology (12). This validation may have lessened the sense of isolation that often fuels trauma responses. Third, the frequency and consistency of communication—twice weekly in this study—appear to foster continuity and trust. For patients facing profound vulnerability and loss of control over daily routines and their health, this consistent presence may have provided meaningful psychological support. The sustained decline in PTSD symptoms suggests that early, relationship-centered care can buffer against the long-term impact of medical trauma.

Finally, integrating the intervention within the inpatient setting made palliative care part of routine, whole-person medicine—not an external consultation for end-of-life care. This normalizing effect may be as significant as the clinical content itself, signaling to patients, caregivers, and staff that palliative care is integral to quality cancer care and solely a consult service for when death is near, as patients, caregivers, and clinicians often perceive it.

This study has several important implications for how transplant programs conceptualize supportive care. First, it challenges the outdated dichotomy between curative and palliative intent. HSCT teams can—and should—incorporate palliative care into their efforts to achieve a cure. Second, it provides a practical implementation model. The intervention’s structure—twice-weekly inpatient visits—demonstrates feasibility without overburdening current staffing models. The intervention ultimately required just over 3 hours per week of a team member’s time, suggesting it could be adapted for outpatient settings or telehealth follow-up to maintain continuity during the vulnerable post-transplant period. Third, the findings emphasize the need to expand palliative care benefits for caregivers. Although caregiver QOL did not significantly improve in this trial, the data reveal an opportunity for more targeted, dyadic interventions that address shared stress and coping. Including family-centered communication and joint coping strategies may improve outcomes for both patients and caregivers in future iterations. Finally, this work aligns with evolving national guidelines. Both the American Society of Clinical Oncology (13) and the National Comprehensive Cancer Network (14) now recommend early palliative care integration for patients with advanced or high-intensity cancer treatments. HSCT provides a clear opportunity to implement these recommendations, transforming episodic consultations into structured, protocol-driven collaborations. As more individuals undergo chimeric antigen receptor T-cell (CAR-T) therapy, could integrating palliative care also be beneficial? Given the shared physical and psychological similarities between HSCT and CAR-T, palliative care makes sense. It is a forward-looking extension rather than a directional implication from the randomized control trial (RCT)’s findings.

Across the cancer treatment spectrum, palliative care remains the most effective yet underused tool. Why is this the case? Despite strong evidence supporting its benefits, many transplant centers lack dedicated inpatient palliative care staff. Misconceptions persist among clinicians and patients that palliative care equals end-of-life care—an idea particularly common in curative settings like HSCT. Educational efforts that emphasize palliative care’s role in supporting recovery rather than signaling failure are crucial. Institutional support is also vital, as successful integration requires leadership backing, workflow adjustments, and measurable outcomes that acknowledge the value of improved QOL and psychological well-being alongside survival. Reimbursement models should encourage proactive palliative care engagement rather than reactive crisis management.

Finally, research must expand beyond academic centers to include community and hybrid transplant programs where most HSCTs are now performed. Adapting to diverse resource environments, such as telehealth services and interdisciplinary training, will be essential for equitable implementation. Building on these findings, elucidating and clarifying mechanisms underlying palliative care’s psychological and emotional benefits would enhance our ability to optimize interventions for patients, caregivers, and healthcare professionals. Understanding why palliative care provides psychological benefits could help refine which components are most essential versus merely helpful. Developing parallel palliative approaches tailored to caregivers’ stress and QOL throughout the transplant process is a promising area for future studies. Lastly, evaluating cost-effectiveness requires staffing models and supportive digital tools that can enable scalable integration across transplant centers. Long-term follow-up beyond 6 months would also help determine whether psychological benefits translate into improved long-term survivorship, adherence, and functional recovery.

This multisite trial confirms that palliative care should be a core component of high-quality transplant treatment, not just an optional addition. This multisite trial with a multicomponent intervention demonstrates the effectiveness and reproducibility of a twice-weekly inpatient palliative care intervention. By enhancing QOL, reducing depression, and alleviating PTSD, early palliative care transforms the transplant experience from mere endurance to supported healing. As hematopoietic transplantation advances, our definition of success and optimal outcomes must evolve as well. Cure is only part of the story; the quality and completeness of life afterward are equally vital. Integrating palliative care into the standard HSCT process is both an ethical and clinical responsibility—an approach that values not only survival but also the preservation of human dignity.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-125/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-125/coif). The authors have no conflicts of interest to declare.

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