Articles of Interest

The Crystal Ball, Does it Exist?

By Karen Reichow, MD, FACP, FAAHPM

The Medicare Hospice Benefit asks an attending physician to certify a patient has a prognosis of six months or less. For many of us, this can be a difficult and stressful process, but it doesn’t have to be that way.

Providers often say, “Please don’t ask me to predict death.” There is no way to know if an individual will die in six months, but we can say individuals who present in the same way generally die in six months.

As an attending physician, realize also the responsibility to prognosticate is shared with the hospice medical director.

Both must certify a life expectancy of six months or less if the illness runs its expected course.

Do we want to take away hope? Our society places high emphasis on cure, yet all of us can recognize when a treatment course is not going well.

Don’t ignore your instincts to communicate this to your patient. The patient with a prognosis of six months is ambulatory and coherent but may be experiencing side effects from curative measures. At four months, there is apparent weight loss, decreased appetite and more pronounced symptoms of the disease.

The last few months show progressive physical deterioration and social withdrawal, requiring total care and intense pain and symptom management.

Discussing end-of-life issues is a time when the bond between patient and physician can be strengthened. Having these conversations earlier in the course of the illness allows a physician-patient team to build a care plan focused on the patient’s goals for quality of life.

Transitioning to palliative treatment options, including hospice, will not be so abrupt or come as a shock.

Six months is only a fraction in the lifetime of most patients. In this short time much work has to be done. From the physician’s perspective, this is a time to transition to palliative care with a focus on pain and symptom management. For the patient, this is a time to put affairs in order, heal grievances and say goodbye.

Being overly optimistic about prognosis or delaying end-of-life care discussions robs the patient of this precious time.

Patients expect your compassion and honesty – both give you the opportunity to heal when the end of life is near.

When to Refer to Hospice

By Karen Reichow, MD, FACP, FAAHPM

During the past 10 years, while the number of patients cared for by hospices has steadily increased, the period of time that people are receiving hospice care is declining. More than half of all hospice patients die within 19 days of admission and more than one-third of hospice patients die within seven days of admission.

Seven days is not enough! It takes time to prepare for end of life, and we want our hospice patients and their families to have the time they need.

When a patient comes to Lower Cape Fear Hospice & LifeCareCenter at the very end of life, the intense focus is on bringing pain and symptoms under control. This does not allow time for our hospice care team to address the emotional, spiritual and social needs of the patient and family or to help them prepare for death. Short lengths of stay with hospice care cheat the patient and family by depriving them of the support they need.

All adults and children with advanced illnesses are candidates for hospice services, not only those diagnosed with cancer. Our patients can receive palliative radiation and chemotherapy, as well as other therapies that improve quality of life.

Some patients improve to be discharged from hospice, but for the majority, this is not the case.

Research has shown patients who receive hospice care live longer than those who do not, although the diagnosis is the same. Our expertise in symptom management, intense monitoring, and improved patient compliance are factors, but the delivery of care by an interdisciplinary team focused on the patient’s goals is key.

Predicting when a patient is entering the last six months of life can be challenging.

That is why the Medicare Hospice Benefit is broken into two initial 90-day periods followed by an unlimited number of 60-day periods. Patients who live beyond the six-month prognosis can continue to receive hospice care.

Would you be surprised if you patient were alive in 12 months? If your answer to this question is yes, then it is time to refer to hospice.

Hospice Care Saves Medicare an Average of $2,309 per Hospice User

Findings of a major  study of hospice care in America show that hospice services save money for Medicare and bring quality care to patients with life-limiting illness and their families. The new study from Duke University appears in the October 2007 issue of the professional journal “Social Science & Medicine.”

The study reinforces what hospice professionals have long known. Study highlights:

  • Hospice reduced Medicare costs by an average of $2,309 per hospice patient.
  • Use of hospice decreased Medicare expenditures for cancer patients until the 233rd day of care and until the 153rd day of care for non-cancer patients.
  • Increasing length of hospice use by just three days would increase savings due to hospice by nearly 10 percent, from around $2,300 to $2,500 per hospice user.
  • Medicare costs would be reduced for seven out of ten hospice recipients if hospice has been used for a longer period of time the study found.

Hospice helps people live with dignity, comfort, and compassion and brings needed support to family caregivers and to know definitively that it provides a cost savings to Medicare is an additional benefit.

According to lead author Don H. Taylor, Jr., assistant professor of public policy at Duke’s Sanford Institute of Public Policy, “Given that hospice has been widely demonstrated to improve quality of life of patients and families…the Medicare program appears to have a rare situation whereby something that improves quality of life also appears to reduce costs.”

Locally, Lower Cape Fear Hospice & LifeCareCenter provides care for more than 600 hospice and palliative patients each day.

Hospice Provides What Americans Want at the End of Life

A nationwide Gallup survey conducted in 2006 produced five key outcomes:
1. Nine out of 10 adults would prefer to be cared for at home rather than in a hospital or nursing home if diagnosed with a terminal illness. Hospice does provide the option of being cared for at a place the patient calls home: 96% of hospice care is provided in the patient’s home or place they call home.

2. An overwhelming majority of adults said they would be interested in the comprehensive program of care at home that hospice programs provide. Yet most Americans know little or nothing about their eligibility for or availability of hospice.

3. When asked to name their greatest fear associated with death, respondents most cited “being a burden to family and friends,” followed by “pain” and “lack of control.” Addressing the whole range of physical and psychological needs of the patient and his or her family in an interdisciplinary way is what makes hospice care so special.

4. 90% of adults believe it is the family’s responsibility to care for the dying. Hospice provides families with the support needed to keep their loved one at home, and can take over fully to give the caretaker short “respite” periods.

5. Most adults believe it would take a year or more to adjust to the death of a loved one. However, only 10% of adults have ever participated in a bereavement program or grief counseling following the death of a loved one. Hospice programs offer one year of grief counseling for the surviving family and friends.

Hospice Patients Lived an Average 29 Days Longer

A study published in the March 2007 issue of the Journal of Pain and Symptom Management reports that hospice care may prolong the lives of some terminally ill patients.

Among the patient populations studied, the mean survival was 29 days longer for hospice patients than for non-hospice patients. In other words, patients who chose hospice care lived an average of one month longer than similar patients who did not choose hospice care.

Sponsored by the National Hospice and Palliative Care Organization, the study was conducted by NHPCO researchers in collaboration with the highly regarded consulting and actuarial firm, Milliman, Inc. Researchers selected 4,493 terminally ill patients with either congestive heart failure (CHF) or cancer of the breast, colon, lung, pancreas, or prostate. They then analyzed the difference in survival periods between those who received hospice care and those who did not. Data came from the Centers for Medicare and Medicaid Services and represented a statistically valid five percent sampling from 1998-2002.

Longer lengths of survival were found in four of the six disease categories studied. The largest difference in survival between the hospice and non-hospice cohorts was observed in CHF patients where the mean survival period jumped from 321 days to 402 days. The mean survival period also was significantly longer for the hospice patients with lung cancer (39 days) and pancreatic cancer (21 days), while marginally significant for colon cancer (33 days).

“There’s an inaccurate perception among the American public that hospice means you’ve given  up,” said J. Donald Schumacher, NHPCO president and CEO. “Those of us who have worked in the field have seen firsthand how hospice can improve the quality of and indeed prolong the lives of people receiving care. Benefits of hospice have been reinforced by positive stories like that of Art  Buchwald who seemed to thrive under the care of hospice.”

Researchers cited several factors that may have contributed to longer life among patients who chose hospice. First, patients who are already in a weakened condition avoid the risks of overtreatmen when they make the decision to receive hospice care. Second, hospice care may improve the monitoring and treatment patients receive. Additionally, hospice provides in-home care from an interdisciplinary team focused on the emotional needs, spiritual well-being, and physical health of the patient. Support and training for family caregivers is provided as well. This may increase the patient’s desire to continue living and may make them feel less of a burden to family members.

“There is a perception among some healthcare providers that symptom relief in hospice, especially the use of opioids and sedatives, could cause patients to die sooner than they would otherwise. This study provides important information to suggest that hospice is related to the longer, not shorter length of survival – by days or months – in many patients,” said Dr. Stephen Connor, NHPCO’s vice president of research and international development, and lead author of the study. “This additional time may be valuable to patients and families to give more time for resolution and closure.”

Co-author Bruce Pyenson, actuary at Milliman, added, “We believe this study helps support the growing quality movement within healthcare. For some patients, hospice care is not a choice about cure – it is a choice for the best care.”

Discussing Prognosis

Real success in discussing prognosis means engaging the patient in a process of growing understanding about their situation, understanding the patient’s evolving information needs, and providing the information in a way that the patient can understand it.

The strength of this approach is that it allows the physician to give each patient what he needs, rather than guess, or assume that what is appropriate for one patient will work for another patient,” the authors conclude. “Physicians using this approach should feel more authentic, more attuned to individual patient needs, and more deeply involved with their medical decisions.”

When discussing prognosis with patients/families, the four step approach is recommended:

Preparation – Content – Patient’s Response – Close

Remember to:

  • Confirm that the patient and family are ready to hear prognostic information. “Would you like me to talk about the prognosis for your disease? What kind of information do you want me to cover?”
  • Present information using a range – few days to weeks; 2-4 months, 3-6 months. “Most people with [your disease] live for months to years. I am hopeful you will do better than most.”
  • Allow silence after you provide information; check for understanding; respond to emotion.
  • “Could you tell me what you are taking away from our conversation today?” and “I know that talking about prognosis can be difficult.”
  • Use prognostic information as a starting point for eliciting end-of-life goals. “Given what we now
  • know about your medical condition, what are your needs and goals?”

Sources: “Discussing Prognosis: ‘How Much Do You Want to Know?’ Talking to Patients Who Are Prepared for Explicit Information,” Journal of Clinical Oncology; September 1, 2006; 24(25):4209-4213. Back AL, Arnold RM; University of Washington, Fred Hutchinson Cancer Research Center, Seattle. Institute for Doctor-Patient Communication, University of Pittsburgh, Pittsburgh. “Discussing Prognosis: ‘How Much Do You Want to Know?’ Talking to Patients Who Do Not Want Information or Who Are Ambivalent,” ibid, pp. 4214-4217. Determining prognosis in advanced cancer. Fast Facts