Each year in the United States, over 1.5 million people are diagnosed with cancer and nearly 600,000 will die of cancer. While cure rates for certain cancers have increased over the decades and survival has lengthened for many incurable cancers, ultimately the vast majority of patients with metastatic disease from most solid tumors and some hematological malignancies will not survive their cancer. As providers for patients with cancer, our aggressiveness toward the care of a patient at the end of life should match the aggressiveness of our attempts to treat patients with surgery, radiation, chemotherapy, or other modalities. Hospice provides that level of aggressiveness at the end of life. However, as Ms Faiman notes, many patients in hospice do not experience the full benefits of hospice care, with 30% admitted to hospice for a less than 1 week and over half of patients in hospice for less than 3 weeks.
As discussed in earlier articles in this series, Conquering the Cancer Care Continuum, palliative care should be integral throughout the care of patients with cancer, whether curable or incurable. However, as patients with incurable cancer move along their treatment continuum, at some point either treatment options may be exhausted or patients’ appropriateness (or desire) for further therapy is lessened. Thus, a shift to a supportive-care-only approach is critical. Such conversations with patients or families are not always easy. Indeed, I will treat patients who have very clear goals from the onset that they do not want to just prolong their time if they do not have quality time. They provide clear direction when they do not want further chemotherapies. On the other side of the coin will be patients with metastatic disease who go from treatment to treatment and, in their cancer life, do not view any other options. In both cases, as well as cases in between, discussion of hospice care becomes critical. When I was in training, one senior physician used to say that just as patients seek a good life, we should help them seek a good death. Patients, and family members, sometimes consider the mention of hospice as an indication of an inevitable end. Given the statistics that Ms Faiman pointed out, it is understandable where that perception is derived from. However, I try to discuss with patients and family that we do not institute hospice early enough, leading neither the patient nor the family to derive the true benefits of hospice. For patients who choose home hospice, having strangers come into their home at the very end, when they are so ill and at the most stressful time in their illness, is more discomforting for patients and family members than instituting hospice early so the hospice providers get to know the patient and family while the patient is well and more communicative. Family members of my patients who are in hospice longer typically provide considerably more positive feedback on the experience than family members of patients on for shorter times (though many who only have hospice for short periods are usually still very appreciative of the services).
The article by Dr Stricker brings forth the importance of considering hospice as team care. For my patients on home hospice, I find communications with the hospice nurse, hospice pharmacist, and hospice director to be critical in helping to best manage patients. Some patients develop more complex symptom management issues, and working together as a team is critical.
In conclusion, I very much concur with Ms Faiman and Dr Stricker that as providers of care for cancer patients, we need to work with patients and family members to dispel the perception that hospice is a place to die; rather it is a place to maximize quality of life for whatever time a patient has to live. Early discussions of the concept of hospice, even while patients are actively on therapy that is controlling their cancer, and reintroduction at different times during the continuum of their care may help patients understand and accept the value of hospice when relevant for their situation.