Understanding their Options: Determinants of Hospice Discussion for Older Persons with Advanced Illness
Purchase on Springer.com
$39.95 / €34.95 / £29.95*
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.
Clinicians’ discussions about hospice with patients and families are important as a means of communicating end-of-life options.
To identify determinants of clinicians’ hospice discussions and the impact of such discussions on hospice use.
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.
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).
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.
- National Hospice and Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. Washington, DC; 2008.
- Rickerson E, Harrold J, Kapo J, Carroll JT, Casarett D. Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better? J Am Geriatr Soc. 2005; 53: 819–23. CrossRef
- Steele LL, Mills B, Hardin SR, Hussey LC. The quality of life of hospice patients: patient and provider perceptions. Am J Hosp Palliat Care. 2005; 22: 95–110. CrossRef
- Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA. 2004; 291: 88–93. CrossRef
- Kapo J, Harrold J, Carroll JT, Rickerson E, Casarett D. Are we referring patients to hospice too late? Patients’ and families’ opinions. J Palliat Med. 2005; 8: 521–7. CrossRef
- Miller KE, Miller MM, Single N. Barriers to hospice care: family physicians’ perceptions. Hosp J. 1997; 12: 29–41. CrossRef
- Miller SC, Kinzbrunner B, Pettit P, Williams JR. How does the timing of hospice referral influence hospice care in the last days of life? J Am Geriatr Soc. 2003; 51: 798–806. CrossRef
- Casarett DJ, Quill TE. “I’m not ready for hospice”: strategies for timely and effective hospice discussions. Ann Intern Med. 2007; 146: 443–9.
- Friedman BT, Harwood MK, Shields M. Barriers and enablers to hospice referrals: an expert overview. J Palliat Med. Feb 2002; 5: 73–84. CrossRef
- Hanson LC, Danis M, Garrett J. What is wrong with end-of-life care? Opinions of bereaved family members. J Am Geriatr Soc. 1997; 45: 1339–44.
- Cherlin E, Fried T, Prigerson HG, Schulman-Green D, Johnson-Hurzeler R, Bradley EH. Communication between physicians and family caregivers about care at the end of life: when do discussions occur and what is said? J Palliat Med. 2005; 8: 1176–85. CrossRef
- Finucane TE. How gravely ill becomes dying: a key to end-of-life care. JAMA. 1999; 282: 1670–2. CrossRef
- Bradley EH, Fried TR, Kasl SV, Cicchetti DV, Johnson-Hurzeler R, Horwitz SM. Referral of terminally ill patients for hospice: frequency and correlates. J Palliat Care. 2000; 16: 20–6.
- Lamont EB, Christakis NA. Physician factors in the timing of cancer patient referral to hospice palliative care. Cancer. 2002; 94: 2733–7. CrossRef
- Richards J, Takeuchi LR. Factors that influence physicians’ recommendation of hospice care: An exploratory study. J Hosp Mark Public Relations. 2006; 17: 3–25. CrossRef
- Summary guidelines for initiation of advanced care. Branford: Connecticut Hospice; 1996.
- Knaus WA, Harrell FE Jr., Lynn J, et al. The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments. Ann Intern Med. 1995; 122: 191–203.
- Murphy DJ, Knaus WA, Lynn J. Study population in SUPPORT: patients (as defined by disease categories and mortality projections), surrogates, and physicians. J Clin Epidemiol. 1990; 43Suppl: 11S–28S. CrossRef
- Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA. 1998; 279: 1187–93. CrossRef
- Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9: 179–86.
- Royall DR, Mahurin RK, Gray KF. Bedside assessment of executive cognitive impairment: the executive interview. J Am Geriatr Soc. 1992; 40: 1221–6.
- Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975; 23: 433–41.
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40: 373–83. CrossRef
- Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of Illness in the Aged. the Index of Adl: a Standardized Measure of Biological and Psychosocial Function. JAMA. 1963; 185: 914–9.
- Pearlin LI, Lieberman MA, Menaghan EG, Mullan JT. The stress process. J Health Soc Behav. 1981; 22: 337–56. CrossRef
- Walke LM, Gallo WT, Tinetti ME, Fried TR. The burden of symptoms among community-dwelling older persons with advanced chronic disease. Arch Intern Med. 2004; 164: 2321–4. CrossRef
- Byock IR, Merriman MP. Measuring quality of life for patients with terminal illness: the Missoula-VITAS quality of life index. Palliat Med. 1998; 12: 231–44. CrossRef
- Casarett D, Van Ness PH, O’Leary JR, Fried TR. Are patient preferences for life-sustaining treatment really a barrier to hospice enrollment for older adults with serious illness? J Am Geriatr Soc. 2006; 54: 472–8. CrossRef
- Weggel JM. Barriers to the physician decision to offer hospice as an option for terminal care. WMJ. 1999; 98: 49–53.
- Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. JAMA. 1999; 282: 1638–45. CrossRef
- A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. N Engl J Med. 1996;335:201–2.
- Casarett DJ, Fishman JM, Lu HL, et al. The terrible choice: re-evaluating hospice eligibility criteria for cancer. J Clin Oncol. 2009; 27: 953–9. CrossRef
- Understanding their Options: Determinants of Hospice Discussion for Older Persons with Advanced Illness
Journal of General Internal Medicine
Volume 24, Issue 8 , pp 923-928
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Yale University School of Medicine, New Haven, CT, USA
- 2. Program on Aging, Yale University School of Medicine, New Haven, USA
- 3. Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- 4. Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA