Authors von Gunten, Lutz, and Ferris have provided oncologists, and all physicians with patients who have cancer, an excellent and pithy review of how those with very advanced cancer are currently cared for as they approach the end-of-life; what hospice and palliative care can offer these patients, the ins and outs of the Medicare Hospice Benefit, and how oncologists and other physicians may successfully navigate the difficult discussions around the transition from active disease management toward a comfort-directed hospice approach to care.
Since 1982, when hospice programs gained the support of the Medicare program under what has become known as the Medicare Hospice Benefit, physicians have gradually become more cognizant of the criteria for admission to hospice; the hospice multidisciplinary team approach to care; the provision of medications, medical equipment, and supplies for patients in hospice; and the emotional, spiritual, and practical support provided to patients and their families as the unit of care. Less well understood are the payment structures for hospice services to the hospice program and to the attending and consulting physicians; levels of hospice care; and locations where hospice care can be provided. Dr. von Gunten clearly and succinctly explains these at times confusing aspects of hospice care.
The greatest barrier to timely referral to hospice lies in physician/patient communication and interaction about prognosis, benefits vs burdens of treatment, and non-disease–oriented treatment options. Lack of knowledge about prognosis and benefit/burden analysis are generally not barriers for the “hospice conversation.” For oncologists, however, the discussions are more complex and difficult. This is perhaps because of the ever-expanding list of possible cancer treatments with modest toxicity, the patient’s willingness to endure significant toxicity for only slight benefit, and the anxiety about how to have such emotionally laden conversations and the distress such discussions can bring to the physician, patient, and family.
Because of the difficult nature of the ‘hospice discussion,’ I would encourage readers to focus attention on the section in the von Gunten article, How to discuss hospice care. Dr. von Gunten’s communication protocol is tried and true among hospice and palliative medicine physicians. It borrows heavily from Buckman’s work on communicating bad news or negotiating goals of care. For a more in-depth review of Buckman’s protocol, I would refer the reader to: SPIKES—A Six Step Protocol for Delivering Bad News: Application to the Patient with Cancer.
Harrington and Smith have recently reviewed in depth the course of a “previously healthy 56-year-old man, who wanted to survive his cancer at all costs. He lived 14 months with three types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly explained.” The authors discuss approaches to communication about prognosis and treatment options as well as questions patients may want answered. Clearly, receiving hospice care in the last days of life virtually concomitantly with receiving a last dose of chemotherapy cannot be called a therapeutic victory!
The American Society of Clinical Oncology position statement, Toward Individualized Care for Patients with Advanced Cancer stated:
Central to all of these goals [viz: individualized care for patients with advanced cancer] is the need for realistic conversations about options and alternatives that should occur throughout the course of the patient’s illness. Such conversations may currently occur in < 40% of patients with advanced cancer. All patients are owed comprehensive information about their prognosis and treatment options, with the amount of detail tailored to the individual patient. All patients must have a regular opportunity to make their preferences about how to live their final weeks and months clear to their oncologist. Given that the default care plan in the absence of these conversations is often further systemic therapy, there is a need to regularly and specifically address the question of whether further anticancer-directed therapy is consistent with the patient’s wishes and the current clinical picture. Only through these discussions do we have the opportunity to match patient’s goals with the actual care delivered.”
In this era of increased emphasis on physician-patient communication (ie, HCAHPS), it behooves all of us to improve and strengthen our communication skills not just for the sake of outcome measurement, but for our patients’ well-being. Involving palliative medicine specialists earlier in the course of a patient's disease course has been shown to result in earlier referral to hospice; less aggressive care in the last weeks of life; and improvements in quality of life measures, mood, and length of life.
Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.