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28 May 2009

Discussing hospice is difficult

Just half of terminally ill lung cancer patients discuss hospice with their health care provider, a new analysis of US national data shows.

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It would be appropriate for all of them to have this conversation, given their prognosis, lead researcher Dr Haiden A Huskamp of Harvard Medical School in Boston told Reuters Health. "Hospice is sort of one piece of a larger conversation about the end of life," she said.

In hospice, patients receive treatment to relieve their symptoms, but forego interventions intended to extend their lives. Hospice also involves caring for a patient's spiritual needs and goals, and includes bereavement help for families after a patient's death.

Talking about hospice care
Many terminally ill individuals don't enroll in hospice care, or only do so in their final days of life, Huskamp and her team note in the Annals of Internal Medicine. They investigated whether having a discussion about hospice with a health care provider would influence whether a patient would be aware of hospice and enroll earlier.

Huskamp's group looked at data for 1,517 patients with late-stage lung cancer from hospitals around the US. The average survival for this stage of lung cancer is four to eight months after diagnosis, Huskamp noted, so she and her colleagues looked at whether patients had discussed hospice with their health care provider within four to seven months of receiving their diagnosis.

Difficult conversation
Fifty-three percent of the study participants had discussed hospice with their health care provider. African American and Hispanic patients were less likely than whites to have had this discussion, as were patients who didn't speak English, and those who were married or had a live-in partner. Individuals who were on Medicaid and those who had undergone chemotherapy also were less likely to have talked about hospice with their doctor.

Three quarters of the study participants who said they would choose relieving pain over extending their lives hadn't discussed hospice with their physicians. One quarter of the study participants also said they wanted to talk with their doctor about their "do-not-resuscitate" preferences, but hadn't done so.

Physicians need to be more proactive
Patients who reported they expected to live for less than two years were more likely to have discussed hospice with their physician, the researchers found. Although just 6% of patients diagnosed with late-stage lung cancer will survive for this long after diagnosis, Huskamp and her team point out, one third of the patients in the study said they expected to live for more than two years.

"Our finding suggests that physicians are not communicating effectively with patients about prognosis or perhaps that some patients may not be fully comprehending discussions of their prognosis with health care providers," the researchers report.

"These conversations are difficult for everyone, they're difficult for patients, they're difficult for families, they're difficult for doctors," Huskamp said in an interview. Many doctors also haven't had the kind of training that might make these discussions more comfortable. "Some patients aren't quite ready to deal with the fact that they may be dying, and that can make it difficult too," she added. –(Anne Harding, Reuters Health, May 2009).

 
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