This study involving older adults with advanced cancer, COPD, and HF demonstrated that clinicians reported hospice discussion for nearly one-half of patients with cancer but only a small proportion of patients with COPD or HF. Although several characteristics suggesting that patients might benefit from hospice were associated with a greater likelihood of discussion, such as moderate to severe symptoms, unwillingness to undergo minor medical interventions, and poorer quality of life, a substantial number of patients with these characteristics did not have the discussion. Other such characteristics, including poorer self-rated health and unwillingness to undergo major medical interventions, were not associated with hospice discussion. The single factor most strongly associated with discussion was clinicians’ estimate of and level of certainty regarding patient life expectancy. However, clinicians failed to identify a sizeable portion of patients who subsequently died within six months. Ultimately, clinicians’ discussion of hospice significantly increased the likelihood of hospice use.
These results are consistent with a previous study in which clinicians cited the difficulty in prognostication to be the greatest barrier to the clinician offering hospice.29
However, in contrast to this earlier study, clinicians did not cite patient preferences for treatment and readiness to handle the discussion as major barriers to discussion. One possible explanation for this difference is that in the current study clinicians were referring to specific patients at specific times rather than citing general barriers to discussion. The 73% of patients who utilized hospice following a discussion with their clinician compares to a previous study asking clinicians to recall the number of hospice offers they had made over a two-year period and also the number of patients that used hospice, resulting in an estimate of a 63% enrollment rate.29
Regardless of patients’ decision to use hospice, the discussion itself is important for patients with advanced illness so they know the options available as their disease progresses. Through conversations about services that may be available to the patient in the future, the clinician may help the patient come to terms with the illness and aid the patient’s transition from being seriously ill to dying.12
The results of this study, showing that patients are largely unaware of alternatives to standard treatment and that clinicians’ discussion of hospice is determined largely by their perceptions and level of certainty regarding patient life expectancy, suggest that many patients who could benefit from such a discussion are not receiving it.
The close relationship in this study between level of prognostic certainty and hospice discussion appears to suggest that improved prognostic information would enhance clinician-patient communication regarding hospice. However, various lines of evidence demonstrate the limited value of focusing on prognostic data. First, clinical prediction criteria based on National Hospice Organization guidelines for patients with COPD and HF have been shown ineffective in identifying persons with a life expectancy of six months or less.30
Second, the provision of such prognostic information to clinicians in the SUPPORT study did not improve clinician-patient communication.31
In order to better identify patients who would benefit from hospice, modifications to the Medicare Hospice Benefit eligibility criteria have been proposed to include factors such as functional status, quality of life, and symptom burden.32
Such an approach would address the many patients in this study whose health status and/or preferences indicated that they might benefit from hospice care but with whom their clinicians did not discuss hospice. The association between life expectancy and hospice discussion in this study suggests that clinicians would need clear guidelines about what should prompt a discussion about hospice care.
One limitation of this study is that clinicians were not asked to describe the nature of discussions that occurred, such as whether they made a recommendation or simply provided information; however, considering the high proportion of participants in this study who enrolled in hospice subsequent to the discussion, one might argue that discussions were largely characterized by the former. Another limitation is data collection by self-report, without independent confirmation that the discussions as reported by clinicians actually occurred. Clinicians, who completed a survey every six months, may have been required at times to recall discussions that took place several months prior. Furthermore, the responses may have been subject to desirability bias. It is also possible that clinicians were more likely to have discussions as a result of their participation in the study.
This study suggests that clinicians’ decisions to discuss hospice for patients with advanced illness are primarily determined by their estimates of life expectancy and the predictability of disease course. Such discussions between clinicians and patients with advanced illness are important so that patients can understand their options and make informed decisions about their care. Given the limitations of prognostication for patients with non-cancer diagnoses, hospice discussions occur primarily for patients with cancer near the end of life. Many patients whose health status and treatment preferences suggest that they might benefit from hospice are not having a discussion with their clinicians about hospice as a treatment option.