Discussions With Physicians About Hospice Among Pa

Authors: Haiden A Huskamp Nancy L Keating Jennifer L Malin Alan M Zaslavsky Jane C Weeks Craig C Earle Joan M Teno Beth A Virnig Katherine L Kahn Yulei He John Z Ayanian

Publish Date: 2009/05/25

Volume: 169, Issue: 10, Pages: 954-962

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Abstract

Methods  We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical recordResults  Half 53 of the patients had discussed hospice with a provider Patients who were black Hispanic nonEnglish speaking married or living with a partner Medicaid beneficiaries or had received chemotherapy were less likely to have discussed hospice Only 53 of individuals who died within 2 months after the interview had discussed hospice and rates were lower among those who lived longer Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms A third of patients who reported discussing donotresuscitate preferences with a physician had also discussed hospiceConclusions  Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis Increased communication with physicians could address patients lack of awareness about hospice and misunderstandings about prognosisHospice includes a broad array of palliative and supportive services that can improve symptom management and quality of life for patients with a terminal illness12 To be eligible for the Medicare hospice benefit which covers 80 of hospice stays3 a physician must certify that a patient has a prognosis of 6 months to live or less and the patient must generally forego lifeextending treatments for the illness Despite the potential benefits of hospice many terminally ill patients receive hospice services only in the final days before death or never enroll45 Factors that may contribute to late or no enrollment include a lack of awareness of hospice inaccurate understanding of ones prognosis or a preference for aggressive treatment of the illness until all nonpalliative options are exhausted611Among patients with advanced cancer discussing preferences about endoflife care with their physicians is associated with less aggressive medical care near death which in turn is associated with better quality of life1213 National guidelines recommend initial discussions about palliative care options including hospice for terminally ill patients with a life expectancy of less than 1 year and the guidelines recommend the reintroduction of this topic as patients approach death1415 However previous studies have documented shortcomings in communication between physicians and patients about endoflife care1619 Physicians often delay discussions with patients about prognosis and endoflife care or do not communicate their true survival estimates2025Although prior studies have shown that fewer than half of patients who die of cancer are enrolled in hospice before their death2627 little is known about how often patients were aware of the option and declined hospice perhaps to pursue treatments that could be life extending or because they were unaware of their prognosis To our knowledge there are no broad populationbased data on discussions regarding hospice between patients with advanced cancer and their physicians In this study we used rich data on a large multiregional cohort of patients with metastatic lung cancer to identify factors associated with whether patients have discussed hospice with their physicians within approximately 7 months of their diagnosis

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