PONE-D-24-45924End-of-life care in hematological malignancies – a nationwide comparative study on the Swedish Register of Palliative CarePLOS ONE

Dear Dr. von Bahr,

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==============================Dear Dr Bahr, please address the methodological and wording issues posed by Reviewer 2.

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This study received funding from Blodcancerfonden

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this paper. I found this manuscript well-written and easy to read. The methodology used was appropriate, and the results clearly and logically presented. The grammar and spelling were of a high quality, however there are a few errors in the reference list. Also, the tables and figures in the supplementary material need labels. This research addresses an important issue, and highlights the lack of palliative care support faced by haematological cancer patients.

Reviewer #2: Thank you for this very important work, it is well needed to highlight the quality at end of life for this group.

Firstly in general regarding the conclusions and results; I think it would be better to "soften" the headings and the language describing the results/conclusions. Can we really say that an outcome is "impacted" by something? I would say "associated with" and/or correlated with depending on what analysis is done- we can not be sure that for example having a hematological diagnosis impacts anything, but is associated with. Throughout the whole manuscript you speak of impact- that is to me to draw the conclusions a bit far. I do understand what you mean, but a more strict language would be appropriate, since you show associations between for example death in an emergency hosptial and worse symptoms.

Another suggestion is to be more clear with you analysis and what has been done?

1. the Swedish palliative register - this is the last week in life? or how long back?

2. Please clarify in methods sections what co-morbidities was classified as exclusion criteria?

3. What were the dependent variables? Did you do a multivariate (several dependent variables) or a multiple regression analyis (one dependent variable)? It is very hard to follow how you did the analysis, which also leads to difficulties in interpreting the results. In line 104 there seems to be a word missing or a comma/period in the wrong place- not sure what is meant? In line 214 in results section- here it is very unclear how this was done? did you add this variable as a co-variate in the analysis-perhaps just how it is written.

I would like a reasoning on excluding unexpected deaths and co-morbidities? I think this is the real situation caring for patients with hematological malignancies, that sometimes death is quick and unexpected, both due to the disease itself, and also the treatment. Maybe clarify why not include also these patients? In line 266 in discussion, you draw the conclusion/reflection that since there was a documented end-of-life conversation, it could be a sign that they did not dy of curative treatment. But the line between curative and not is very fine in hematological patients, and it might be considered a curative treatment even if very slim chance- so not sure I follow this line of reasoning.

Another comment is that it could be that the unexpected deaths (that is excluded in you study), would be patients whith a very slim chance of cure, that died during or in complications of treatment, were totally "ignored" in terms of palliative needs, and this may be to a large extent impacting your results- so wish a more in depth method discussion on the choice to exclude these patients?(if I understood the meaning of an unexpected death in the right way)?

Furhter, line 295-7 in the discussion, is this really the only explanation? could it not be that for example pain assessment or oral assessments are done but not documented (thus not captured when registering in register?)- can we really assume that the missing data cohort have poorer quality of care at end of life? I agree with your reflections, but would be good to mention these institutions that do not even register in this registry?

I am overall in the discussion missing the reasoning on how to integrate palliative care in this group. We need to hava a palliative approach already during the treatment, and pursue both lines simultaneously- that is even a more challenge in my experience, and if we are going to provide high quality of end-of-life care for hematological patients in an emergency hospital, we need to talk about this. If a small chance of cure, what do we do and plan and hope for if this does not work? The solution can not be that as long as patients get palliative home care or hospice all is good.

In summary I welcome this important work, and with some clarifications this will be a good contribution to the body of research on patients with hematological malignancies and the need of palliative care/approach.

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Reviewer #1: No

Reviewer #2: No

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End-of-life care in hematological malignancies – a nationwide comparative study on the Swedish Register of Palliative Care

PONE-D-24-45924R1

Dear Dr., von Bahr,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Rosemary Frey

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: After reading through the revisied manuscript and reviewer responses, I am satisfied that the authors have addressed all reviewer comments. Thefore, I reccommend that the manuscript should be accepted for publication.

Reviewer #2: Thank you for you thorough replies and good luck in future. I look forward to more contribution to research on this group of patients.

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Reviewer #1: No

Reviewer #2: Yes:  Helena Ullgren

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