Cancer Patients Could Benefit from Earlier Referral to Hospice: Dartmouth Report
Part of being a world-class hospice care provider is sharing new findings in our industry. Dartmouth recently found that earlier conversations around end-of-life wishes could enable more cancer patients to live out final days in comfort and dignity at home. Read the full analysis:
In a newly released national analysis of Medicare patients, researchers at Dartmouth find that, though the numbers of terminal cancer patients receiving hospice care has risen slightly in recent years, many are entering hospice in the very last stages of illness - often within days of death. Despite research indicating that most cancer patients prefer to die at home, many are still dying in hospitals, in the ICU unit, and dependent on ventilators.
In a report from the Dartmouth Atlas Project, “Trends in Cancer Care Near the End of Life,” the authors of the study indicate that recent “trends in end-of-life cancer care have been mixed.” Specifically, they write, “While patients are spending fewer days hospitalized in the last month of life, the number of days in ICUs has increased.” While days spent in hospice care have also increased during this time period, the number of patients entering hospice programs in the last three days of life has alsorisen. For this growing number of patients, enrollment arrives too late to provide the full benefits of hospice care.
The authors of the study do note significant improvements in end-of-life quality indicators during the first decade of the 21st century. For example, the number of cancer patients dying in the hospital declined from 28.8% in 2003 to 24.7% in 2007. There was also a significant increase, from 54.6% to 61.3%, in the percentage of patients who enrolled in hospice in the last month of life.
Dartmouth researchers describe a US medical system that continues to emphasize the most intense forms of hospitalized treatment for terminally ill cancer patients. They report that the use of highly invasive life-sustaining treatments, such as intubation, feeding tubes and CPR in the last month of life remained largely unchanged during the study period. “Similarly, the average [percentage] of patients receiving chemotherapy during the last two weeks of life was virtually unchanged.”
The research seems to indicate that patients may be receiving more fragmented care, as the percentage of “patients who saw ten or more different physicians during the last six months of their lives rose from 46.2% to 58.5%.” Researchers cite “uneven” improvement, varying “markedly across regions and hospitals.” “In analyses of Medicare data that control for patient age, sex, race, tumor type and non-cancer chronic conditions, the chances that a patient with advanced cancer died in the hospital in 2010 varied from one in eight (13%) to one in two (50%) depending on the medical center providing their care.” This was true even among National Cancer Institute-designated Cancer Centers.
Poor communication skills may bear some of the blame for these less-encouraging statistics. The report’s authors say, “While there is increased awareness of the importance of discussing personal care preferences with cancer patients, deficiencies in communication are common.” Having end-of-life conversations is important, they explain, because it tends to counter “a general trend towards more aggressive care in the last months of life.” In the absence of explicit conversations about end-of-life wishes, high-intensity care is often the default setting, which is “associated with poor quality of life and of death, as well as higher costs, and, in some cases, reduced survival.”
Though the frequency of end-of-life discussions is increasing over time, “cancer treatment has become more aggressive in general.” Despite increased communication and emphasis on talking through end-of-life wishes, “it could be that some patients prefer more aggressive care, or do not fully understand - or accept - that their life expectancy is limited when expressing their preferences.” Sometimes, though, end-of-life conversations may simply happen too late in the process to have a major impact on quality of treatment. Whatever the underlying causes of the present emphasis on high-intensity care for terminally ill cancer patients, Dartmouth researchers suggest, “there is more work to be done to ensure the wishes of cancer patients” are followed at the end of life.
The Atlas Project report includes a large amount of data displayed in charts and tables. The full report, press release, related data tables, and other resources are available online at www.darmouthatlas.org.