By Ileana Leyva, MD
When a patient’s advanced cancer no longer responds to curative treatments, they may be eligible for end-of-life care. Yet, oncologists often overestimate the patient’s survival trajectory. In most cases, patients with cancer are not referred to hospice until they have only a few days left to live.1
This means the patient misses receiving the full Medicare Hospice Benefit (MHB)—with costs relating to the terminal diagnosis covered at 100 percent for those eligible—along with the care services that enhance their quality of life and assist family caregivers. If the prognosis for the patient is a life expectancy of six months or less if the illness runs its normal course, many are eligible to receive the MHB.
Realistic Prognosis Leads to Quality-of-Life Decisions and Reduced Rehospitalizations
Evidence shows the benefits of hospice for patients with advanced illness. Hospice is associated with reduced pain intensity, symptom burden, and psychological distress; improved quality of life; decreased usage of non-beneficial aggressive care; and increased likelihood of death in a preferred location (most often at home). Hospice also decreases the frequency of non-beneficial hospitalization and invasive procedures.1-4
Despite these advantages, oncology patients may be reluctant to accept their disease severity or may perceive hospice as ‘giving up.’ By presenting options to patients and families, clinicians enable them to choose end-of-life care that reflects their values and preferences:
- Set aside time to conduct a goals-of-care conversation. This discussion is associated with improved end-of-life outcomes, goal-concordant care for the patient, and reduced anxiety and depression for family members.
- Communicate the prognosis and disease trajectory, giving the patient realistic expectations to allow for planning.
- Educate the patient and their loved ones so they understand the full scope of options to make informed decisions. No loved one should be left saying, “I wish I had known.”
- Listen and speak on their terms. Faith background, cultural traditions, and socioeconomic status can shape a person’s views of end-of-life care. Make the conversation productive by staying mindful of the cultural, generational, and personal beliefs involved. Discern who makes or influences the decisions in the family. Pause before providing unsolicited advice.
Delayed Hospice Care Leads to Deferred Benefits: Refer Sooner
Early hospice referral guides patients to symptom-based care plans, interdisciplinary team care, and specialized services. Delaying such care reduces patient satisfaction. Hospitals may see these patients more often in emergency readmissions as their disease state progresses.
In addition, the reduced costs related to stopping ineffective treatments can be significant. Medicare beneficiaries with cancer who used hospice for 31-60 days had a difference of 6% compared with beneficiaries who did not use hospice. For cancer patients with longer hospice stays, the difference increased further: 61-90 days 9% less, and 90-180 days 13% less.5
Do you have patients with advanced cancer who are not improving? They are hospice-eligible if they have:
- Progressed through first-line treatment and spend 50% of waking hours in a bed or chair
- An average life expectancy of ≤ 3 months
- Indicated they are no longer interested in pursuing anti-tumor therapies
To refer your hospice-eligible patient to VITAS, contact us anytime at 800-938-4827. Dr. Leyva is regional medical director, VITAS® Healthcare.
1 Waldrop DP, Meeker MA, Kutner JS. Is it the difference a day makes? Bereaved caregivers’ perceptions of short hospice enrollment. J Pain Symptom Manage 52:187-195.e1, 2016.
2 Finnigan-Fox G, Matlock DD, Tate CE, et al. Hospice, she yelped: Examining the quantity and quality of decision support available to patients and families considering hospice. J Pain Symptom Manage 54:916-921.e1, 2017.
3 Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300:1665-1673, 2008 22.
4 Trevino KM, Prigerson HG, Shen MJ, et al. Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment. Cancer 125:3259-3265, 2019.
5 NORC at the University of Chicago. Retrieved from Value_Hospice_in_Medicare.pdf (nhpco.org)