Predicting Patient Survival Before and After Hospice Enrollment

SUMMARY

Despite the apparent advantages of hospice care, several barriers exist in terms of patient referral. Physicians’ prognoses play a large role in determining when hospice care should begin. Predicting patient survival is a subjective decision dependent on several factors that vary before and after hospice enrollment. Currently, the stay of patients in hospice is very short; this can be attributed to late referral by physicians. Additional research on physician behavior and prognostication could help optimize the use of hospice as a valuable health care resource, thereby improving end of life care for terminally ill patients. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: [email protected]]

Notes

Regarding the Medicare benefit, see, for example, F.A. Davis (1988). Medicare Hospice Benefit: Early Program Experience. Health Care Financing Review 9, 99-111.

See, for example, R. Buchman (1992). How to Break the Bad News. Baltimore: Johns Hopkins Press.

For example, see D. Luchins; P. Hanrahan (1993). What is Appropriate Health Care for End-Stage Dementia? JAGS 41, 25-30.

See, for example, R.S. Schonwetter et al. (1990), 65-79. In the ease of dementia, for example, 80% of hospices identified this difficulty in predicting survival time as the major problem in serving dementia patients; see P. Hanrahan; D.J. Luchins (1995). Access to Hospice programs in End-Stage Dementia: A National Survey of Hospice Programs. JAGS 43, 56-59.

See for example, N.A. Christakis (1994), 314-320.

Finding that race or gender is associated with survival, even after adjusting for other measurable patient attributes, would tend to support this contention, since there is little reason to believe that race or gender would influence mortality when one is considering the last few months of life.

A sophisticated randomized trial would probably be required to definitely sort out the relative importance of these two factors. Since patients would probably have to be willing not only to be randomized either to hospice or conventional care, but also to be randomized to receive hospice referral at different times in the course of their disease, such a study is essentially un-doable. However, other methods may eventually afford an answer to the question of the relative importance of t_e and t_d in duration of survival after referral.

Regarding physicians’ predictions in general see N.A. Christakis; G.A. Sachs (1996). The Role of Prognosis in Clinical Decision Making. Journal of General Internal Medicine 11(7), 422-425.

Additional information

Notes on contributors

Nicholas A. Christakis

Nicholas A. Christakis, MD, PhD, MPH, is Assistant Professor of Medicine and Sociology, Departments of Medicine and Sociology, University of Chicago.