Physician Involvement Boosts Hospice Referral

Nursing home patients are more likely to enroll in hospice care at the end of life if their health care team is involved in the decision to refer them to a program. That was the conclusion of a study published recently in JAMA (2005;294:211–217) that examined an intervention designed to pull physicians into the process sooner.

“Hospice is the gold standard for end of life care,” said David Casarett, MD, MA, lead author of the new study. “For most patients and families in most settings, the single best way to get access to a highly-trained interdisciplinary team is through hospice.”

Hospice services are covered by Medicare for people 65 and older. Yet many patients who could benefit from hospice services never enroll, or only do so within a few weeks—or even a few days—of their death.

“If we could take care of people for longer, we could do more good,” said Casarett, who is director of the Palliative Care Consult Service at the Philadelphia Veterans Affairs (VA) Medical Center.

Casarett has done previous studies of hospice, looking at factors that lead people to enroll. A common theme emerging in the earlier work, he said, is that “patients and families often wait for physicians to begin the hospice discussion—and they wait and they wait and they wait.”

Doctors may be reluctant to bring up the topic of hospice because they are not certain how the patient or family might respond, Casarett said.

“Enough of us as physicians have had that experience where you come into a room and say, ‘Things are looking bad, maybe it's time to think about hospice,’ and you're met with a distraught patient or family member who thinks you're abandoning them,” he said. “All it takes is one bad conversation like that to make a physician gun shy.”

With this latest work, he and his colleagues hoped to find a way to “jumpstart” this potentially difficult conversation.

The study included residents of three nursing homes, including the VA facility where Casarett works, who were randomized into two groups. Trained interviewers spoke with the residents (or the person responsible for making decisions about their care) to identify hospice-appropriate patients. The control group received usual care. Hospice-appropriate patients were given a brief description of hospice services and told they could learn more by speaking with their physician.

But the researchers asked members of the intervention group for permission to contact their doctor directly about enrolling in hospice. Those doctors then got a fax from the researchers letting them know they had a patient who was a good candidate for hospice care and asking them to authorize a consultation.

Of 35 patients in the intervention group who were candidates for hospice, 21 enrolled in a program within 30 days, and six additional patients had enrolled by the 6-month mark. Of 49 hospice-eligible patients in the control group, just one enrolled in a program in the first 30 days, and five additional patients had enrolled by the 6-month mark.

People in the intervention group also spent much more time in hospice (mean 64 days) than people in the control group (mean 14 days). Also, people in the intervention group were much less likely to be hospitalized than people in the control group.

In general, Casarett said, people who are in hospice care have decided they do not want to be in a hospital setting—although, of course, they are free to change their minds and get hospital care if it is needed.

Another important finding from the study is that families of people in the intervention group were more satisfied with the end-of-life care their loved one received than families of people in the control group. That was true even though people in the intervention group were no more likely to be enrolled in hospice at the time of their death, nor to die in the nursing home rather than an acute care setting.

“But the main difference is that they spent more time in hospice. So even if this intervention doesn't result in more people dying in hospice, they spend more time in hospice. Who's enrolled at the time they die may not mean as much as the care they got the previous week or previous month,” explained Casarett.

“Hospice does a lot to prepare patients and also families for death, both in terms of focusing on pain and symptom management, and emotional and spiritual support,” said Casarett. “But we don't know what hospice did to make people more satisfied. Was it better pain management? Was it better emotional support? We just know hospice is very important in improving satisfaction with care.”

Casarett said his group is doing other studies to determine exactly what it is about hospice that helps families feel better about the care their loved ones get. 

Figure  .

Nursing home patients were more likely to enroll in hospice, and stayed in a program longer, when their doctor was prompted to take part in the decision.