The vast majority of physicians would choose hospice care for themselves if they received a terminal cancer diagnosis, according to participants in a multiregional study, but less than one-third would discuss hospice care with a terminally ill cancer patient early in treatment.
A research letter published in JAMA Internal Medicine also identified factors that increased the likelihood that physicians would choose hospice care for themselves and examined how their preferences related to the timing of end-of-life care discussions with patients.
“Having timely discussions with terminally ill cancer patients to establish goals for end-of-life care is important to maximize the quality of patient care. But by and large we’re not doing a good job at having these discussions early on,” said lead author Garrett Chinn, HMS instructor in medicine at Massachusetts General Hospital. “We know that patients facing terminal illness often wish to spend their remaining days at home, surrounded by loved ones. Since end-of-life care in the U.S. often stands in stark contrast to these preferences, it’s important to identify factors that may facilitate cost-effective care that supports patient preferences.”
The current study was conducted as part of the Cancer Care Outcomes Research and Surveillance (CanCORS) study, a consortium of centers across the country measuring the quality of care delivered to 10,000 patients with newly diagnosed lung or colorectal cancer. This report reflected answers to two survey questions from nearly 4,400 physicians caring for cancer patients—including primary care physicians, surgeons, oncologists, radiation oncologists and other specialists.
The respondents were asked how strongly they agreed with the statement, “If I were terminally ill with cancer, I would enroll in hospice.” They were also asked when they would discuss hospice care with an asymptomatic patient with terminal cancer who they estimated had 4 to 6 months to live: right away, when symptoms first develop, when no more options are available to treat the cancer, when the patient is admitted to the hospital or when the patient or family asks about hospice care.
In response to the question about personal hospice enrollment, 65 percent reported strong agreement with the statement, and 21 percent indicated they agreed “somewhat.” Physicians who were female, who cared for more terminally ill patients or who worked in managed-care settings were more likely to indicate strong agreement. Surgeons and radiation oncologists were less likely than primary care physicians or oncologists to show strong agreement.
Only 27 percent of respondents overall said they would discuss hospice care with the described patient “now.” Waiting until symptoms appear was the choice of 16 percent and 49 percent would bring it up when no more therapeutic options were available. Upon hospital admission or when asked by a patient or family member each were chosen by 4 percent. Among physicians who strongly agreed that they would personally enroll in hospice care, almost 30 percent responded that they would discuss hospice care with the patient “now,” while about 20 percent of all other respondents would do so.
“Our results suggest that most doctors would want hospice care for themselves, but we know that many terminally ill cancer patients do not enroll in hospice,” said Nancy Keating, HMS associate professor of health care policy and senior author of the JAMA Internal Medicine paper. “In the overall CanCORS study, only about half of the patients who died of metastatic lung cancer had ever discussed hospice care with their physician. Our findings suggest that doctors with more negative personal preferences about hospice care may delay these discussions with patients, which indicates they may benefit from learning more about how hospice can help their patients.”
Chinn added, “Although a physician’s personal care preferences may be quite important, we still do a poor overall job having timely end-of-life care discussions with our terminally ill cancer patients. A lack of knowledge about guidelines for end-of-life care for such patients, cultural and societal norms, or the continuity and quality of communication with patients and family members are also factors that might act as barriers preventing physicians from ‘practicing what they preach’ in end of life care.”
The CanCORS study and the current report were supported by grants from the National Cancer Institute and the Department of Veterans Affairs.
Adapted from a Mass General news release.
