The American Society of Clinical Oncology recommends that those patients with advanced cancer receive palliative care soon after they are diagnosed and receive hospice care for at least the last three days of their life. There are major gaps between these recommendations and the real-life practice, according to a study.
The care received by all veterans over the age of 65 with cancer who died in 2012, a total of 11,896 individuals, was examined by Risha Gidwani, DrPH, a health economist at Veterans Affairs Palo Alto Health Economics Resource Center and a consulting assistant professor of medicine at Stanford University School of Medicine.
They found that 71% of the veterans received hospice care, but only 52% received palliative care. Exposure to hospice care differed significantly between patients treated by the U.S. Department of Veterans Affairs and those who were enrolled in Medicare. Many of the patients who received palliative care received it late in their disease’s progression rather than immediately following diagnosis, as was recommended by ASCO.
The study by Gidwani is published online in the Journal of Palliative Medicine. Vincent Mor, PhD, a professor of health services, policy and practice at Brown University was the senior author.
Hospice and palliative care are confused but are also two very distinct services. Palliative care is intended to alleviate symptoms and improve quality of life and appropriate for all patients with serious illness and not just those who are at the end of life. Hospice care is an end-of-life service that can also provide social support for family members. Hospice care can only be ordered by a doctor if he believes the patient has fewer than 180 days left to live.
Improved exposure to palliative care needs to be reviewed, both in terms of how many patients receive it and when they receive it. The team’s analysis of palliative care focused on the care provided by the VA because this care is not coded consistently in Medicare. When the timing and provision of hospice care between patients treated by the VA and those who received care paid for by Medicare, it was discovered by the team there were differences that could not be explained by cancer types. Those patients receiving VA care were less likely to receive hospice care for the minimum of 3 days compared with those in Medicare. VA patients received hospice care a median of 14 days before death whereas those patients in VA-contracted care entered hospice a median of 28 days prior to death.
Obviously, Medicare and the VA have different policies on the use of hospice care as VA cancer patients can continue receiving curative treatment while in hospice care but Medicare patients must stop any chemotherapy or radiation before entering hospice. There were also differences in the use of hospice and palliative care between cancer types and ages. Those with brain cancer were more likely to receive palliative care than those with kidney cancer, as an example.
About 85.6% of veterans had some exposure to hospice care or palliative care in the 180 days prior to death. There are opportunities to improve access to care for patients older than 85 who are likely to have several medical ailments. Early palliative care increases both longevity and quality of life. Some doctors report they are unsure about the prognosis and that is why they refer patients late, even though the earlier referrals are better.
The study was funded by the U.S. Department of Veterans Affairs.
–Dr Fredda Branyon