For patients who think being admitted to hospice will shorten their lives, a new study offers striking evidence to the contrary. Based on an analysis of end-of-life data on nearly 4,500 adults—about 4,000 of them cancer patients—the study (J Pain Symptom Manage 2007;33:238–246) showed that patients who received hospice care lived 29 days longer, on average, than patients who did not.
The survival benefit was strongest for patients with congestive heart failure and cancers of the lung, pancreas, and colon. Patients with breast and prostate cancers did not show a statistically significant benefit, the study concluded.
“There is still a strong perception among the public and professionals that you give up and maybe die sooner when you enter hospice,” said the study's lead author, Stephen R. Connor, PhD, Vice President of Research for the National Hospice and Palliative Care Organization (NHPCO).
“Clearly, further research is needed,” said Dr. Connor, a clinical psychologist who has worked in the hospice field for more than 30 years. “What we can say pretty strongly is that the notion that patients who go into hospice die sooner is not true.”
Hospice experts welcomed the report, but were not completely surprised by the findings. The very nature of hospice care, involving supportive care and close case management, usually in the patient's home, is a likely explanation, said Janet L. Abrahm, MD, Director of the Pain and Palliative Care Program at Dana-Farber Cancer Institute.
“I think there are a lot of indirect benefits to hospice care, and I wouldn't be surprised if they helped the patient live longer,” Dr. Abrahm said.
Tani Bahti, RN, CT, CHPN, a Tucson hospice nurse and educator, said the study “absolutely will help us counter the idea that if you're going to start someone on morphine, you're going to shorten their lives.
“People don't always want to introduce the idea of hospice because they feel it's taking away,” Ms. Bahti said. “But using this study they can present hospice as elevating the level of care.”
Betty Ferrell, RN, PhD, FAAN, a City of Hope research scientist whose work focuses on end-of-life care, also said the findings were “not at all a surprise.
“My response is, of course, because it's sort of what we've all known and lived and believed for a long time,” Dr. Ferrell said. “These patients get really good care, they get their pain managed, they get their symptoms managed, they get psychological and spiritual support. So it really makes sense what this study has found.”
The NHPCO sponsored and conducted the study with the actuarial firm Milliman Inc. “We believe this study helps support the growing quality movement within health care,” Milliman actuary Bruce Pyenson, a coauthor of the study, said in a statement. “For some patients, hospice care is not a choice about cure; it is a choice for the best care.”
Follow-up to Earlier Study Showing Hospice Costs Medicare Less than Other End-of-Life Care
The study was a follow-up to an earlier study by Dr. Connor and Mr. Pyenson that showed that hospice care costs Medicare less than other end-of-life care. That study, reported in the same journal in September 2004, also suggested a hospice survival benefit, which led to the second study.
Patient data for both studies came from Centers for Medicare and Medicaid Services claims data. The new study looked at data on 4,493 terminally ill patients, representing a statistically valid 5% sample of Medicare enrollees from 1998 to 2002.
Of the total, 2,095 patients—47%—received hospice care for at least one day. Of those, 83 were diagnosed with congestive heart failure; 158 with breast cancer; 337 with colon cancer; 700 with lung cancer; 493 with pancreatic cancer; and 324 with prostate cancer.
The greatest survival benefit was seen in patients with congestive heart failure—those enrolled in hospice had a mean survival of 402 days, compared with 321 days for those not in hospice.
For cancer patients enrolled in hospice, the survival benefit was 39 days for those with lung cancer, 21 days for pancreatic cancer, and 33 days—marginally significant, the authors said—for patients with colon cancer. Breast and prostate cancer patients did not derive a statistically significant benefit from hospice care, however.
The study did not show why hospice patients had an overall longer survival time, but Dr. Abrahm and others said careful case management, strong social support, and less exposure to infection, medication errors, and other hazards of hospital care were likely contributors.
“Hospice is trying very hard to keep people out of the hospital and keep them at home,” Dr. Abrahm said. “Nurses are coming to the home, they're focusing on the well-being and the functionality of the patient, and they're feeding that back to the doctors.
“So you're getting close observation and really good communication, and that leads to better care.”
Ms. Bahti is a former oncology nurse who recently authored a book, CD, and DVD called Dying to Know, in response to patients' questions about end of life. She offered additional reasons for the longer survival times for hospice patients.
Unrelieved pain means the patient is “being bathed in stress hormones,” which increases the risk of blood clots, heart failure, and infection, and can accelerate tumor growth, Ms. Bahti said. In addition, patients who are post-surgery often experience some breathing impairment and are more susceptible to pneumonia and other respiratory problems, she said.
“And especially when you're dealing with the elderly, those infections are more likely to lead to death.”
Many physicians will still be surprised to read of the new evidence of longer life in hospice care, Ms. Bahti and Dr. Ferrell said.
“I think there is still a mindset that hospice is where you go to die,” Dr. Ferrell said. “Sadly, people who should have been referred to hospice two or three months ago usually get referred to hospice just days before they die.”
She noted that 30 years ago, when she started in nursing, she would be talking to someone on a plane or in a grocery line and if she said she was involved in hospice, the other person would say, “What's that?”
“But now, when I meet someone on a plane or train or grocery store, and I talk about hospice, nine times out of 10 people will say, ‘Oh, my brother was in hospice’ or ‘Oh, my mother was in hospice.’ And the next sentence out of their mouth is, ‘Boy, what incredible care they got.’ Sadly, the next thing they say is, ‘Boy, if we knew then what we know now, we would have started hospice months sooner.’”
Hospice Facts & Figures
- ▪ Since the first hospice program opened in New Haven, Connecticut, in 1974, the field has grown to more than 4,100 programs today.
- ▪ About 68% of programs are nonprofit; 27% are for-profit; and 5% are government-run.