Doctors, lung cancer patients skirt hospice talk

The typical patient with metastatic lung cancer lives four to eight months after diagnosis. Yet barely more than half of doctors caring for these patients discuss using hospice care to help manage these last months of life, according to a May 25 Archives of Internal Medicine study.

Bringing up hospice when patients and families often want to keep fighting the cancer is a challenge for doctors, said study co-author John Z. Ayanian, MD, professor of medicine and health care policy at Harvard Medical School in Massachusetts.

"But in situations like this, where the overall prognosis is poor, it's important for physicians to have open and honest discussions so that patients understand their options and don't suffer when good palliative care could make their remaining quality of life much better," Dr. Ayanian said.

Researchers interviewed 1,517 patients or their families four to seven months after a stage IV lung cancer diagnosis and asked whether they discussed hospice with a physician or other health professional. Overall, 53% of patients said they had talked about hospice with a professional. Black and Hispanic patients were about 25% less likely to have had the discussion, the study said.

Patients who talked about hospice with their doctors were about three times more likely to take advantage of the service, which Medicare covers. Previous research has shown that less than half of Medicare patients who die of cancer do so in the care of a hospice program. Still, researchers said they were surprised by how often hospice wasn't discussed, given the gravity of the diagnosis.

"Guidelines say that doctors should have initial discussions about end-of-life care when there is a one-year survival prognosis, and then maybe reintroduce the topic over time," said the study's lead author, Haiden Huskamp, PhD, associate professor of health care policy at Harvard. "In this case, it was surprising because these patients are, in a sense, an extreme example, given the relatively short prognosis common for their condition, yet they still hadn't discussed hospice by the point we interviewed them."

Other experts on end-of-life and cancer care said the findings confirmed their anecdotal experience.

The study "reflects how hard it is for both patients and doctors to talk about approaching the end of life, and that's why there aren't a lot of discussions and not a lot of talk about hospice," said Anthony L. Back, MD, professor of oncology at the University of Washington School of Medicine.

"A lot of patients equate talking about hospice to talking about death," he said. "It's not like talking about, 'Hey, here's another service here that will be helpful.' As much as we try to portray it like that, it's a very loaded conversation."

Though doctors may get a don't-give-up message from patients and families, it is up to physicians to take the initiative to talk about hospice, said Dr. Back, an oncologist at the Fred Hutchinson Cancer Research Center, part of the Seattle Cancer Care Alliance.

"The ball is in the court of the physicians," he said. "The profession has a responsibility to do a better job with this to figure out how to make these discussions less terrifying, less threatening, more practical and more caring for patients. ... When patients hear physicians talking about hospice, they think doctors are going to abandon them. That is one of the unspoken subcurrents of this whole thing."

The hospice discussion also is time-consuming, and that time is largely unreimbursed, said Gail Austin Cooney, MD, president of the American Academy of Hospice and Palliative Medicine.

"All the incentives are lined up against having these kinds of conversations," said Dr. Cooney, who added that research shows patients in hospice have high rates of satisfaction with their care.

But Dr. Cooney, a hospice medical director in West Palm Beach, Fla., said she understands from personal experience why physicians are reticent to bring up hospice. Her mother died of heart failure in the hospital in May.

"All of her physicians knew which way things were going, yet everybody kept putting off the talk," Dr. Cooney said.

"I could see things weren't getting better, but it took several days for me to get up the courage to talk with her about it. And I know how to do this. ... Things are not as black and white as I once thought they were."

The print version of this content appeared in the June 22, 2009 issue of American Medical News.

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