Patients Living Longer With Hospice
Wednesday September 5, 2007
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The largest difference in survival between the hospice and non-hospice cohorts was observed in CHF patients in which the mean survival period jumped from 321 days to 402 days. The mean survival period also was longer for the hospice patients with lung cancer (39 days), pancreatic cancer (21 days), and colon cancer (33 days).
Sponsored by the National Hospice and Palliative Care Organization, the study was conducted by the organization’s researchers in collaboration with the consulting and actuarial firm Milliman Inc.
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According to findings in a new study, “Comparing Hospice and Nonhospice Patient Survival Among Patients Who Die Within a Three-Year Window,” patients with some terminal conditions, including congestive heart failure and lung and pancreatic cancer, who chose hospice care lived an average of one month longer than patients with similar conditions who did not choose hospice care. The study was published in the March 2007 issue of the Journal of Pain and Symptom Management (JPSM).
Experts in hospice care say these results have far-reaching implications and help to correct misperceptions about hospice care, including a belief that the liberal use of opioids and sedatives in hospice causes patients to die sooner than they would otherwise.
“The big news is that you don’t die sooner in hospice, and it’s icing on the cake to know that for some diagnoses, hospice patients may actually live longer,” says Carol Spence, RN, MS, co-author of the study and director of research for the National Hospice and Palliative Care Organization in Alexandria, Va.
Spence also believes this study may open the door to a much-needed cultural change in health care.
“There is a pervasive thinking in our culture that when you have a terminal illness, you should fight until the end,” she says. “There is now quantifiable hard evidence to help dispel the myth that when you go into hospice, you’ve given up and you’re going to die sooner.”
Researchers say the data also can be a tool for hospice nurses and providers when educating referral sources about hospice services. In turn, hospice care providers can refer to the data when discussing options and treatment plans with patients with life-limiting illnesses.
“For providers, it gives them an evidence base and a sense of confidence in recommending and being an advocate for hospice,” says Kathryn Fitch, RN, MEd, co-author of the study and principal healthcare consultant for Milliman Inc. in New York City.
Despite the promising findings, researchers emphasize there is need for further study. “A lot of questions are raised by these kinds of findings, and it points to the need to do more research on the specific factors that might come into play,” says Stephen R. Connor, PhD, lead researcher in the study and vice president for research and international development for the National Hospice and Palliative Care Organization.
“There are a number of different pieces to the puzzle,” says Diane Bergeron, RN, BSN, MSM, president of the Hospice and Palliative Care Federation of Massachusetts and executive director of Hospice Care Inc. in Woburn, Mass. “Hospice pays for all medications and may even take them to the [patient’s] home, which can improve access for patients.”
Hospice also may help healthcare teams keep a closer watch on patients. Next, because care is provided by a consistent interdisciplinary team focused on supporting the emotional needs, spiritual well-being, and physical health of patients and families, hospice services may increase a patient’s desire to continue living. In addition, hospice care providers are available around the clock to assist and guide families in any care issues that arise, which improves timeliness of care and minimizes stress.
“We take the pressure off of the family and decrease patient and family anxiety,” says Bergeron. “Hospice allows you to be a family member.”
Hospice patients cared for in the home also avoid potentially life-threatening complications such as hospital-acquired infections. Additionally, there may be a longevity benefit for some terminally ill patients who choose hospice and stop aggressive treatments, such as chemotherapy, radiation, and transplants, which might offer only marginal potential for benefit and a significant potential for life-threatening complications.
“For patients in the study who didn’t choose to take that route, it isn’t surprising that they lived longer, because they weren’t dealing with the burdens of those treatments,” says Nancy E. Harte, RN, MS, CHPN, director of LIFE Institute for Rainbow Hospice in Park Ridge, Ill.
Harte says in her practice she has witnessed patients rally after entering hospice. This phenomenon has been dubbed the “honeymoon period” by some hospice providers. Harte stresses that patients have the best chance of experiencing this improvement when they are referred to hospice early in their terminal illness and have more than a few days or weeks to live.
“The perception is that after getting into hospice, patients die quickly when, actually, they were dying quickly anyway,” she says. “If patients are brought into hospice early enough, they will have enough time to experience the full benefit of how it can improve quality of life and, in many instances, longevity of life.”
Bergeron concurs but is concerned that the study findings may be interpreted as implying that by living longer, patients in hospice care will also suffer longer. She stresses that hospice professionals are experts in managing pain and symptoms so patients are comfortable in their last days and are able to realize goals and dreams, such as attending a family wedding or celebrating another Christmas.
Both studies have important implications for the current healthcare milieu, which is focused on building quality programs while using resources appropriately and economically, says Jeff Lycan, RN, BS, president/CEO of the Ohio Hospice and Palliative Care Organization.
“If the hospice model can more appropriately provide people less invasive care and improve their quality and outcomes, it may dramatically change the way we use aggressive life-sustaining treatments,” he says. “This means more attention to symptom management and control versus the traditional curative medical model under which most providers fall.”
Lycan hopes researchers outside the hospice industry will expand upon the positive findings of both studies. He believes more research could build the evidence base needed to help providers reexamine the relative benefit/risk ratios of some aggressive interventions and better meet the goals of a variety of patients at the end of life. For example, the congestive heart failure cohort in the new study had the longest life span of all diagnoses studied in hospice.
“Yet, cardiology is one of the more difficult places for hospice to get referrals because of the multiple mechanical and medical management interventions that are used for individuals in late stages of life,” says Lycan.
Catherine Spader, RN, is a contributing writer. To comment on this story, e-mail jboivin@gannetthg.com.
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