Palliative, rather than life-prolonging or curative care, is the primary goal for hospice patients. As a result, despite the higher quality of life and better pain management that has been observed in hospice patients,40,41
there is a concern that hospice care might be associated with shorter survival compared to ongoing anticancer care outside of a hospice.
In accordance with the previous literature,9,27–32,42
our data have shown that baseline characteristics, including age at diagnosis, gender, race/ethnicity, urban residence, experiencing care in a teaching hospital, and comorbid conditions were associated with choice of hospice care,30
although hospice availability did not affect length of hospice admission among those with hospice care. After controlling for these baseline characteristics by using the multiple Cox regression analysis and the propensity score analysis, we could not detect a detrimental effect on survival by entering hospice, as expected.6–8
However, these traditional logistic regression models could be biased because admissions to hospices are likely to be confounded by unobserved variables. Therefore, we attempted to remove residual selection bias by choosing the regional availability of hospices as an IV. Results from the IVA indicate that regional availability of hospice was associated with any hospice use, but not with length of hospice stay. Instead, experiencing aggressive end-of-life care was more predictive of (shorter) duration of hospice use. Despite a significant relationship between aggressive end-of-life care and no or only short-term hospice stay, hospice patients were found to have comparable or even longer survival compared to nonhospice patients based on three different statistical approaches.
Advances in medical technologies and a perception that patients favor receiving aggressive care even very near death for small expected benefits may reduce the number of patients referred to hospice,9,10,43,44
especially in the black patients.45
Short-term hospice use was not associated with longer survival, suggesting that continuing aggressive care close to death did not necessarily translate into better outcomes or inaccurate estimation of the prognoses. Together, these data suggest that provider or patient preferences and resource considerations, rather than clinical factors, may be driving end-of-life care for marginal patients.
Our study had several limitations. First, this study cohort did not include patients aged less than 65 years and those insured by an HMO in the Medicare program so the current results cannot necessarily be generalized to younger patients and those with managed care insurance. However, 60% of cancer cases occur in patients aged 65 or older46
and Medicare covers the majority of cancer patients in the United States.47
In addition, although a previous study showed that Medicare beneficiaries with managed care insurance were more likely than those with fee-for-service insurance to enroll in hospice and stay longer, the length of hospice stay for most hospice patients was less than one month regardless of whether they were enrolled in managed care or fee-for-service.48
We did not capture information if patients, who elected their hospice benefit, withdrew later. Our study was limited to patients who had died from lung cancer, which is the leading cause of cancer mortality in the United States, but the choice of hospice use, treatment options, and/or clinical outcomes for these patients may differ from those with other types of cancer.6,42
As with any study using administrative data, the accuracy of some of the variables used, including the identification of hospice use and the calculation of the comorbidity score, may be limited.49,50
Lastly, selection bias cannot be completely excluded without randomization. For example, physicians may be more likely to refer patients to hospice when they think they are going to live long enough to benefit from it.
In conclusion, use of hospice and length of hospice stay for Medicare patients with advanced NSCLC did not compromise survival. Appropriate timing of referral to hospice gives terminally ill cancer patients and their families more time and opportunity to benefit from palliative services and avoid futile interventions. Concern about hastening death should not be a barrier to hospice care.