Association between advanced cancer patient‐caregiver agreement regarding prognosis and hospice enrollment

Abstract

BACKGROUND: Patients with advanced, incurable cancer who understand their illness is incurable are more likely to prefer hospice care at the end of life compared with patients who believe their illness is curable. To the authors' knowledge, it is unclear whether patient-caregiver agreement regarding perceived prognosis is associated with hospice enrollment. METHODS: The current study examined the prospective relationship between patient-caregiver agreement concerning perceived prognosis and hospice enrollment in the last 30 days of life. Data were collected during a cluster randomized controlled trial examining a communication intervention for oncologists and patients with advanced cancer and their caregivers. At the time of study entry, patients and caregivers (141 dyads) were categorized as endorsing a "good" prognosis if they: 1) reported a >50% chance of surviving ≥2 years; or if they 2) predicted that the patient's quality of life 3 months into the future would be ≥7 on an 11-point scale. RESULTS: Approximately one-fifth of dyads agreed on a poor prognosis whereas approximately one-half disagreed regarding prognosis. In approximately one-third of dyads, patients and caregivers both believed the patient's future quality of life would be good (34%) and that the patient would live for ≥2 years (30%). Patients in these dyads were less likely to enroll in hospice compared with patients in dyads who disagreed and those who agreed on a shorter life expectancy and poor future quality of life. CONCLUSIONS: Dyadic understanding of patients' projected life expectancy and future quality of life appears to be predictive of care received at the end of life. Improving rates of hospice enrollment may be best achieved with dyadic interventions. Cancer 2019;125:3259-3265.

Reply to Hope, optimism, and the importance of caregivers in end‐of‐life care

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We appreciate the letter from Kako et al regarding our examination of the relationship between advanced cancer patient-caregiver agreement regarding perceived prognosis and hospice enrollment within the last 30 days of life. 1 In general, we agree with Kako et al and welcome this opportunity to expand our discussion of this important topic.Kako et al raised questions concerning how and when prognostic information should be provided that are critical to the translation of research into clinical care. A highly structured formulaic approach to prognostic discussions is unlikely to be effective when working with individual patients who vary with regard to disease status, emotional readiness for prognostic information, and caregiver support, among other factors.

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“…We appreciate the letter from Kako et al regarding our examination of the relationship between advanced cancer patient-caregiver agreement regarding perceived prognosis and hospice enrollment within the last 30 days of life. 1 In general, we agree with Kako et al and welcome this opportunity to expand our discussion of this important topic.…”

“…Our study highlighted the importance of an additional factor: caregiver prognostic understanding and agreement with the prognostic understanding of the patient. 1 We believe that oncologists should elicit caregivers' perspectives regarding prognosis, in addition to those of the patient. A simple question to caregivers such as, "what are your thoughts on this information" may be adequate for identifying gaps in caregiver prognostic understanding and discrepancies between patients and caregivers.Kako et al stated that rates of hospice enrollment in our study 1 were similar in dyads who disagreed and dyads who agreed on a good prognosis.…”

Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer

“…1,2 Several studies have demonstrated that prognostic understanding affects health care use and advanced care planning. [3][4][5][6][7] Therefore, there is a need to improve prognostic understanding so that patients receive care concordant with their goals. Caregivers (generally family members or friends) play an integral role in the care of older adults, 8 and many participate in prognostic discussions and assist patients with treatment decision making.…”

Hope, optimism, and the importance of caregivers in end‐of‐life care

“…We read with great interest the recent article by Trevino et al 1 The authors concluded that the rates of hospice enrollment differed according to patient-caregiver agreement regarding the patient's prognosis and perception of future quality of life. These results are very interesting, but we would like to highlight 3 concerns.…”