A first-of-its-kind study recently published by the Journal of Palliative Medicine encourages doctors to discuss hospice with patients sooner in the course of a terminal disease.¹ In many cases, if not the majority of cases, doctors do not tell their dying patients about hospice.² However, when doctors tell their patients about it, the likelihood that a patient will receive hospice nearly triples.³ This is widely considered a good thing. Research connects hospice care with multiple benefits:^4-11

• Greater overall satisfaction with the entire healthcare experience
• Improved quality of life
• Reductions in the emotional impact on surviving family
• Fewer rehospitalizations
• Medicare savings of roughly $9,000 per patient
• Lower costs for families
• Patient survival improved by days to months

What is a Hospice Conversation?

These conversations are referred to as end-of-life conversations, hospice conversations, and palliative care conversations, somewhat interchangeably. Doctors explain to patients that their diseases are likely life-limiting. They introduce the subject of end-of-life care documents. They should also summarize palliative care and hospice care, so families can be aware and begin researching.

Hospice Conversations Have Known Benefits

Aside from the advantages of hospice, the conversations themselves are also connected with important benefits for patients and the healthcare system. One study found that these hospice conversations correlated with higher quality of life for patients and improved bereavement for families.¹² Hospice conversations within three days of a hospital admission are known to reduce expenses by more than $3,000 per patient.¹³

Most Fears Surrounding Hospice Conversations are Proven Myths

Doctors frequently cite concerns for a patient’s emotional wellbeing as reasons for not having the hospice conversation. They don’t want to rob the patient of hope or cause depression. Sometimes they fear damaging the doctor-patient relationship. Contrary to these popular myths, research shows that hospice conversations do not help or harm the doctor-patient relationship, do not depress patients, and that the hospice conversation improves patient quality of life.^{14, 15}

When to Have the Hospice Conversation

What has previously not been well established is when doctors should have the hospice conversation. It has been proposed that this conversation should happen when the doctor estimates a patient has one year to live. This would be six months before a patient qualifies for hospice and would give families time to learn about palliative care.

Recently, Joan Carpenter, PhD took a novel approach and used data to estimate the best timing for a hospice conversation.¹ Her research team analyzed the billing and medical records of 5,592 patients who received a hospice or palliative care conversation in the last six months of life. Surviving family members then completed a survey about their satisfaction with overall end-of-life care. Generally speaking, they found that the earlier the conversation, the better the results. Families with earlier hospice conversations rated higher satisfaction with overall care, respect, communication, and emotional/spiritual support.

The big limitation of this study was that it only analyzed the last six months of life, and the very best results were from the earliest hospice conversations. This suggests the possibility that even better results could have been had from conversations between 12 and 6 months. So, while Dr. Carpenter’s study cannot make us sure that six months is the best time for a hospice conversation, this data does assure us that hospice conversations at six months are better than later hospice conversations.

Related Articles:

• Why Doctors Don’t Tell Patients Their Life Expectancy
• What’s the Difference Between Hospice and Palliative Care

References:

1. Carpenter JG, McDarby M, Smith D, Johnson M, Thorpe J, Ersek M. Associations between timing of palliative care consults and family evaluation of care for veterans who die in a hospice/palliative care unit. Journal of Palliative Medicine. 2017 Jul 1; 20 (7): 745-51.
2. Daugherty C, Hubocky F. What are terminally ill cancer patients told about their expected deaths? A study of cancer physicians’ self-reports of prognosis disclosure. J Clin Oncol. 2008; 26: 5988-5993.
3. Thomas J, O’Leary J, Fried T. Understanding their options: determinants of hospice discussion for older persons with advanced illness. J Gen Intern Med. 2009; 24(8): 923-8.
4. Obermeyer Z, Makar M, Abujaber S, et al. Association between Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer. JAMA. 2014; 312 (18): 1888-1896.
5. Lah S, Wilson E, Brown SM. The association between hospice utilization and performance on publicly reported outcome measures. In A14. Advance Care Planning and Palliative Care: Patients to Policy 2016. (pp. A1015-A1015). American Thoracic Society.
6. Azoulay D, Jacobs JM, Cialic R, Mor EE, Stessman J. Opioids, survival, and advanced cancer in the hospice setting. Journal of the American Medical Directors Association. 2011 Feb 1;12(2):129-34.
7. Wright A Keating N, Balboni T, et al. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol. 2010; (29): 4457-4464.
8. Kris A, Cherlin E, Prigerson H, et al. Length of hospice enrollment and subsequent depression in family caregivers: 13-month follow-up study. Am J Geriatr Psychiatry. 2006; 14 (3): 264-269.
9. Teno J, Clarridge B, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA. 2004; 291 (1): 88-93.
10. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17(9):1054-1063.
11. May P, Garrido MM, Cassel JB, Morrison RS, Normand C. Using length of stay to control for unobserved heterogeneity when estimating treatment effect on hospital costs with observational data: issues of reliability, robustness, and usefulness. Health Serv Res. 2016;51(5):2020-2043.
12. Wright A, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008; 300 (14): 1665-73.
13. May P, Normand C, Cassel JB, Del Fabbro E, Fine RL, Menz R, Morrison CA, Penrod JD, Robinson C, Morrison RS. Economics of palliative care for hospitalized adults with serious illness: a meta-analysis. JAMA Internal Medicine. 2018 Jun 1;178(6):820-9.
14. Enzinger, Andrea C., et al. Outcomes of prognostic disclosure: Associations with prognostic understanding, distress, and relationship with physician among patients with advanced cancer. Journal of Clinical Oncology. 2015; 33 (32): 3809-3816.

Wright A, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008; 300 (14): 1665-73.