Doctors von Gunten, Lutz, and Ferris accurately point out some of the reasons for the tragic underutilization of hospice care and ways oncologists might address this issue. Unfortunately these leaders (and I) have been making similar appeals for decades, to little effect.
The reason that oncologists do not refer patients to hospice earlier has to do in part with their workload. The incidence of cancer is rising much faster than the number of trained oncologists, putting a strain on the workforce. The American Society of Clinical Oncology and the Association of Medical Colleges estimate that by 2020 there will be a deficit of 2550 to 4080 oncologists.[1]
Oncologists are also the best-paid specialists in internal medicine,[2] and integrated health plans cannot afford to hire very many of them. Thus, because of conflicting work demands, few oncologists are able to set aside the amount of time that Dr. von Gunten et al describe, to really listen to the concerns of patients and families facing the end of life and help them sort out what to do next.
Another challenge for oncologists, as the authors point out, is in guessing what services the hospice can provide to their patients. Large hospices, particularly those in Florida and California, can offer radiation therapy to palliate bone metastases, bisphosphonates to prevent fractures, and palliative procedures such as thoracentesis or paracentesis when indicated. Smaller hospices rarely offer such treatments, as their financial performance (or very survival) could be adversely affected.
In Canada and Europe, “hospice” and “palliative care” services are not distinct, but in the United States hospice eligibility and reimbursement is determined by the Medicare Hospice Benefit.[3] To address some of the problems that Dr. von Gunten and coauthors point out, hospital-based, home-based, and clinic-based palliative care services are emerging.[4] These services can offer some of the extremely valuable benefits of hospice, such as symptom management and family support, much earlier in the course of the cancer patient’s illness.
After nearly two decades as a hospice medical director, I now work for a palliative care service in an integrated care system. It is quite common for us to be consulted before the patient has learned the results of the first biopsy. From “day one” we utilize many of the methods that Dr. von Gunten et al describe to provide comprehensive, interdisciplinary care to patients and their families.
Some of the services that a palliative care team can offer include symptom management and psychosocial support that often allow cancer patients to continue with their therapies. We commonly diagnose life-threatening complications and get patients the acute care they need. Oncologists are generally very happy to have us work with them, because doing so eliminates many distress calls for symptom management issues and spares them long and sometimes difficult discussions with patients and families about care planning. Oncology nurses and social workers work very closely with us, to optimize patient care. Follow-up palliative care conversations often occur in the infusion center while the patient is receiving chemotherapy.
As our relationship with the patient and family grows, they come to view the center as “a safe place” where they can discuss fears, doubts, and concerns about the future. Early in our relationship, we begin talking about the continuum of palliative care services that includes hospice.
One of our principal concerns is making sure that patients get the most effective care at each stage of their illness, in keeping with their goals and the medical realities of their condition. Good communication with the oncologist and other specialists is essential and is now becoming routine. We are particularly concerned about what should happen the next time the patient has a symptom-control problem or other crisis after hours.
In the first hour that returning to the hospital is not the best plan for the patient (ie, no reversible causes of symptoms are likely and/or further disease-oriented care is not available or desired), we work very hard to get the patient into hospice care immediately. Patients who have completed their last disease-oriented therapy should not have to wait for a crisis to occur before moving on to the most effective service for managing their future care needs - hospice care. If our patient has special needs (eg, if blood transfusions, octreotide(Drug information on octreotide), paracentesis, or radiation are still of benefit) we are on the phone with the medical director of the hospice. Patients deserve coordinated, carefully executed transfers so that care remains effective and seamless.
In summary, I believe oncologists should work closely with an experienced interdisciplinary palliative care service beginning on the day on which the cancer is diagnosed, to make sure their patients get the best care. Randomized trials, such as those performed by Kaiser Permanente,[5] confirm that patients get better symptom management, families are more satisfied with care, thousands of dollars are saved per patient, and hospice lengths of stay are considerably longer. As Dr. von Gunten et al note, recent trials suggest that longevity may be increased as well. This can occur whether oncologists refer to hospice earlier or not.
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.
