The Terrible Choice: Re-Evaluating Hospice Eligibility Criteria for Cancer

Abstract

Purpose To be eligible for the Medicare Hospice Benefit, cancer patients with a life expectancy of 6 months or less must give up curative treatment. Our goal was to determine whether willingness to make this choice identifies patients with greater need for hospice services. Patients and Methods Three hundred patients with cancer and 171 family members were recruited from six oncology practices. Respondents completed conjoint interviews in which their perceived need for five hospice services was calculated from the choices they made among combinations of services. Patients' preferences for treatment were measured, and patients were followed for 6 months or until death. Results Thirty-eight patients (13%) said they would not want cancer treatment even if it offered an almost 100% chance of 6-month survival. These patients, who would have been eligible for hospice, did not have greater perceived need for hospice services compared with other patients (n = 262; mean, 1.75 v 1.98; Wilcoxon rank sum test, P = .46), nor did their family members (mean, 1.95 v 2.04; Wilcoxon rank sum test, P = .80). Instead, independent predictors of patients' perceived need for hospice services included African American ethnicity, less social support, worse functional status, and a greater burden of psychological symptoms. For families, predictors included caregiver burden, worse self-reported health, working outside the home, and caring for a patient with worse functional status. Conclusion The requirement that patients forgo life-sustaining treatment does not identify patients with greater perceived need for hospice services. Other characteristics offer a better way to identify the patients who are most likely to benefit from hospice.

Nurse and physician inter-rater agreement of three performance status measures in palliative care outpatients

“…A PPS of ≤60 is increasingly being used to assess eligibility for home care services based on the observation that this population requires more home support [1]. Assessing Physical distress subscore includes ESAS pain, fatigue, nausea, drowsiness, appetite, and shortness of breath items; psychological distress subscore includes anxiety and depression items a All p values are <0.001 eligibility for hospice or home care using performance status criteria may be more appropriate than using clinical assessment of prognosis, which is notoriously optimistic for both physicians and nurses [23,35], or willingness to give up curative treatment, which does not identify those with greater perceived need for services [8]. However, our study shows that physicians may rate patients as being healthier than nurses using the PPS scale, and this should be kept in mind when using the scale for this purpose.…”

Understanding their Options: Determinants of Hospice Discussion for Older Persons with Advanced Illness

“…31 In order to better identify patients who would benefit from hospice, modifications to the Medicare Hospice Benefit eligibility criteria have been proposed to include factors such as functional status, quality of life, and symptom burden. 32 Such an approach would address the many patients in this study whose health status and/or preferences indicated that they might benefit from hospice care but with whom their clinicians did not discuss hospice. The association between life expectancy and hospice discussion in this study suggests that clinicians would need clear guidelines about what should prompt a discussion about hospice care.…”

The expanding role of primary care in cancer control

“…225 Prognostic estimates are notoriously optimistic, 226 which might delay the commencement of a palliative approach and increased support, particularly in countries such as the USA where hospice services are linked to a prognosis of less than 6 months. 227 Once PCPs are involved in palliative care, barriers at an organisational level might surface. Dutch PCPs reported that arrangement of home care services or procedures such as oxygen therapy, intravenous medications, or paracentesis is time-consuming and that extra care (eg, assistants to aid with care, such as nurses) is diffi cult to obtain.…”