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Title of Journal: Arch Intern Med

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Abbravation: Archives of Internal Medicine

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Discussions With Physicians About Hospice Among Patients With Metastatic Lung Cancer

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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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 record.Results  Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English 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 do-not-resuscitate preferences with a physician had also discussed hospice.Conclusions  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 prognosis.Hospice includes a broad array of palliative and supportive services that can improve symptom management and quality of life for patients with a terminal illness.1,2 To be eligible for the Medicare hospice benefit, which covers 80% of hospice stays,3 a physician must certify that a patient has a prognosis of 6 months to live or less, and the patient must generally forego life-extending 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 enroll.4,5 Factors that may contribute to late or no enrollment include a lack of awareness of hospice, inaccurate understanding of one's prognosis, or a preference for aggressive treatment of the illness until all nonpalliative options are exhausted.6-11Among patients with advanced cancer, discussing preferences about end-of-life care with their physicians is associated with less aggressive medical care near death, which in turn is associated with better quality of life.12,13 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 death.14,15 However, previous studies have documented shortcomings in communication between physicians and patients about end-of-life care.16-19 Physicians often delay discussions with patients about prognosis and end-of-life care or do not communicate their true survival estimates.20-25Although prior studies have shown that fewer than half of patients who die of cancer are enrolled in hospice before their death,26,27 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 population-based 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.



citation_title=Development of the Palliative Care Needs Assessment Tool (PC-NAT) for use by multidisciplinary health professionals.; citation_author=Palliative Care Research Program team; citation_author=Waller A; citation_author=Girgis A; citation_author=Currow D; citation_author=Lecathelinais C; Palliat Med; citation_year=2008; citation_volume=22; citation_issue=8; citation_pages=956-964;

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