Ms. D is a 45-year-old woman with ovarian cancer and hepatic metastatic disease. She has received multimodal treatment over the past 5 years. Ms. D lives in her own home, is divorced, and is a single parent of two adolescent children. Her mother is her primary caregiver and also has a deteriorating health condition.
Ms. D’s functional status is very poor. She was enrolled in a phase I clinical trial, however a further decline in functional status, coupled with increased symptoms and diminished renal function, required that she withdraw from participation in the trial.
Her cancer has progressed with extensive peritoneal involvement and increased ascites that are managed with a peritoneal catheter. She and her children have stopped talking to one another and there is increased tension between Ms. D and her mother. Ms. D has begun to question her spirituality and feels that God is punishing her.
She does not want her health care providers to think that she is “giving up and throwing in the towel.” She was admitted to the hospital with intractable nausea and vomiting and a possible malignant bowel obstruction. She has no advanced care planning and is a full code. As oncology nurses, we need to assess the situation and ask ourselves, “Is this patient appropriate for referral to hospice care?”
As Americans, we live in a death-denying society, surrounded by expansive, advanced technology and interventions that can extend and prolong life at all costs. We have made great strides in cancer care through early detection, prevention, and treatment, yet a significant number of patients still do not survive their disease. In 2008, for example, the American Cancer Society estimated 1,437,180 new cancer cases (all sites) and 565,650 deaths.[1] Most people who have survived cancer and completed their course of treatment live with the underlying fear and uncertainty that their cancers may return. While some people with advanced cancer are living longer and with improved quality of life, hospice care is a choice that provides a unique set of benefits, services, and support.[2]
Although patients and families report that they are satisfied once enrolled in hospice level of care, many patients are referred too late or not at all.[3] Less than one-third of patients receive hospice care near the end of life and those who are referred die within days.[4] The transition to hospice care, including the establishment of a trusting relationship with the interdisciplinary team, takes some time, and patients with very short lengths of stay cannot reap all of the benefits of hospice care.[5] Because oncology nurses are typically the mainstay during patients’ and families’ course of cancer care, they stand at the forefront in assisting patients with complex end-of-life care decisions and in facilitating end-of-life care discussions.
The Hospice Foundation of America defines hospice as comfort and supportive care given to patients and their loved ones when illness does not respond to treatments that have curative intent.[6] The philosophy of hospice is to provide the total care of patients who have a life-limiting illness. This includes meeting patients’ physical, social, spiritual, and psychological needs. The goal of hospice is neither to prolong life nor hasten death, but rather to maximize quality of life for patients as they travel along this last journey.
Patients, regardless of age, are eligible to receive hospice care if their physicians certify them as having a life expectancy of 6 months or less, should the disease follow its expected course. While it is the role of the physician to recommend hospice care, it is the patient’s right and decision to determine when hospice is appropriate and which program suits his needs. Although insurance coverage for hospice is available through Medicare, most private insurance plans, including HMOs and other managed care organizations, include hospice level of care as a benefit. Forty-four states in the US have a Medicaid Hospice Benefit. Also, through community contributions, memorial donations, and foundation gifts, many hospices can provide free services to patients unable to pay for them. Other programs charge in accordance with ability to pay.
