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Chapter 56: Hospice Care and End-of-Life Issues

Charles F. von Gunten; David E. Weissman

Updated chapter to come.

HOSPICE CARE

Hospice Care

The number one complaint about hospice care from patients and families is that no one told them about it sooner. Referral for hospice care is appropriate when the most important goal is comfort rather than making the cancer better. If patients improve or resume anticancer therapy, they can be discharged (graduate) and resume services later without penalty

 

Eligibility: Prognosis of less than 6 months if a patient's disease runs its usual course. Individual patients can continue to be eligible if they live longer than 6 months as long as their physician believes death is more likely than not within 6 months. A patient does not need a DNR order. There is no limit to the number of days a patient can receive hospice care. There is no penalty if a physician is wrong about a patient's longevity

 

Prognosis: Oncologists overestimate prognosis when compared with actual survival. Referral for hospice care is associated with an increase in survival as compared with controls

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General Indicators of Poor Prognosis Specific Indicators of Poor Prognosis

Performance status:

Karnofsky 10 or 20 (ECOG/Zubrod 4): <1 month

Karnofsky 30 or 40: 1–2 months

Karnofsky 50 (or ECOG/Zubrod 3): 2–3 months

Hypercalcemia: 6 weeks

Multiple brain metastases: 3–6 months

Anorexia: <2 months

Delirium/confusion: <1 month

Dyspnea: <1 month

Nutritional status:

Serum albumin <2.5 mg/dL: <6 months

Specific cancers:

Stage IV non–small cell lung cancer: 6–12 months

Unresectable pancreas cancer: 4–7 months

Stage IV esophagus cancer: 3–6 months

Stage IV gastric cancer: 7 months

Discussing Hospice Care

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Discussing Hospice Care
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One of the biggest barriers to timely referral for hospice care is physician discomfort with the discussion

Clinical pearl: Discuss hospice care after determining broad goals of care (if focus of care is comfort, to be as independent and comfortable as possible, hospice helps achieve the goals)
Steps Suggested Phrases
1. Establish the setting: privacy, time “I'd like to talk with you about our overall goals for your care”
2. What does the patient understand? Get the patient talking

“What do you understand about your current health situation?” or

“What have the doctors told you about your cancer?”
3. What does the patient expect? Correct misperceptions

“What do you expect in the future?” or

“What goals do you have for the time you have left—what is important to you?”
4. Discuss hospice care “You've told me you want to be as independent and comfortable as possible. Hospice care is the best way I know to help you achieve those goals.” Never say, “There's nothing more we can do”
5. Respond to emotions Be quiet. The most profound initial response a physician can make is silence, providing a reassuring touch, and offering facial tissues. The most frequent mistake is to talk too much

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