Too Many Patients Are Delaying Hospice Care

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Although hospice can benefit terminally ill patients over a period of time, one in six cancer patients enroll it in only during the last three days of life, according to a new study.

The findings, by researchers from the University of Pennsylvania’s Perelman School of Medicine, also revealed a profile of the kind of patient who is most at risk of these late admission.

“Waiting until the final days of life to begin hospice can shortchange patients and their families – skipping over many benefits of hospice care and limiting the opportunity to improve patients’ quality of life during this stressful time,” said study co-author David Casarett, MD, a professor of Medicine and director of Hospice and Palliative care at Penn Medicine.

“Our findings point to some reasons why patients may seek hospice care so late in the course of their illness, which we hope will enable us to improve transitions to hospice at a more beneficial point in their care.”

In the study, the team examined the electronic medical records of 64,264 patients in 12 hospices; the patients’ identities were removed from the records. The facilities analyzed are part of the Coalition of Hospices Organized to Investigate Comparative Effectiveness network, and the records covered the period from January 2008 to May 2013. Of the 64,264 patients, 10,460 had a hospice stay of three days or fewer.

Patients in that category, the study found, were likelier to be male, married, younger than 65, and nonwhite. Patients with blood cancers and liver cancers were likelier to be admitted within the last three days of life than were patients who had oral cancer. The blood-cancer patients may wait, the researchers said, because they depended on blood products that hospice doesn’t provide; these patients are also likelier to have a more abrupt decline.

People who were on Medicaid or who had no health insurance usually enrolled in hospice earlier than those who had Medicare or health insurance. The investigators said that this might be because poorer patients can’t afford aggressive or experimental treatment that would keep them out of hospice.

The researchers say the association of marriage with late admission may be because marriage can provide a caregiving structure that supports continued treatment. The investigators also said that patients may continue their treatment for the sake of their spouse.

The study could help health-care providers in identifying patients at risk for later hospice enrollment and in beginning discussions about hospice earlier.

A different patter of care may also have a financial effect: Health-care facilities and oncology practices may someday be reimbursed partly based on the percentage of their patients who enroll near the end of life.