, Volume 24, Issue 8, pp 923-928
Date: 09 Jun 2009

Understanding their Options: Determinants of Hospice Discussion for Older Persons with Advanced Illness

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ABSTRACT

BACKGROUND

Clinicians’ discussions about hospice with patients and families are important as a means of communicating end-of-life options.

OBJECTIVE

To identify determinants of clinicians’ hospice discussions and the impact of such discussions on hospice use.

DESIGN

We interviewed 215 patients age ≥ 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice.

RESULTS

In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians’ estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians’ discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3–13).

CONCLUSIONS

Clinicians’ discussion of hospice for patients with advanced illness, and, ultimately, patients’ use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.

The research reported in this manuscript was supported by P30 AG21342 from the Claude D. Pepper Older Americans Independence Center at Yale University and R01 AG19769 from the National Institute on Aging. Dr Fried is supported by grant K24 AGAG028443 from the National Institute on Aging.