While most patients suffering from terminal illness express a desire to remain at home, studies show that patients are often not enrolled in hospice care services that support this goal until their final days. This often leads to repeat visits to the emergency room.
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A recent study, presented at the Innovation Challenge session of the McGill International Congress on Palliative Care, found that identifying high-risk patients and formulating an individual care plan can lead to earlier referrals to hospice. This earlier intervention results in better management of patients’ symptoms while reducing intensive care unit stays and readmissions in the acute care setting.
“Most patients who are frequently being readmitted in the emergency room are the ones needing more help at home for their care,” says study author Ruth Lagman, MD, a hospice and palliative medicine specialist at Cleveland Clinic’s Taussig Cancer Institute. “Hospice delivers interdisciplinary care and resources so patients can stay at home and have their pain, nausea and other symptoms controlled. In addition, hospice teams provide psychosocial support at this difficult time.”
Dr. Lagman was part of a team of palliative medicine and oncology physicians, nurses and social workers who came together to analyze high emergency room utilization at Cleveland Clinic over a 60-day period. Upon finding that the vast majority of readmissions were due to a very small subset of patients with advanced cancer, they delved further into the data to better understand how to support these individuals and their families. “Upon further analysis, we realized the individuals being readmitted frequently were also the ones needing to be referred to hospice care,” says Dr. Lagman.
Based on the complexity of the cases, the team developed individual care plans for each patient, and communicated those back to the outpatient team. Their identification and support of these patients led to earlier recognition of hospice eligibility. Of the 112 patients discussed, 85% were referred to or had a hospice discussion and 82% enrolled. The median days in hospice was 11, compared to a median of three days prior to these interventions.
With the disease trajectory of cancer rapidly changing and patients living longer, physicians often have questions about when the optimal time is to refer patients for hospice care. When patients are still undergoing active treatment, palliative care supports patients and families in concert with cancer providers. If those treatment modalities are exhausted, that is generally when a patient becomes eligible for hospice care.
“While the guidelines say that the patient’s life expectancy should be six months or less to be eligible for hospice, this is just a guide and each situation is evaluated on a case-by-case basis,” Dr. Lagman explains. “Sometimes, because patients and families received additional support in hospice, they have an overall better quality of life and may actually live longer.”
People often mistakenly believe that once they’re in hospice they can’t transition out of it, but that’s not the case. “If someone is living longer or perhaps a clinical trial opened up that offers them a new treatment option, they can disenroll from hospice,” she said. “It’s very fluid.”
Earlier access to hospice care benefits patients and families. However, late referrals to hospice continue due to lack of understanding about how it can help or reluctance to introduce the topic. Encouraging patients to have an informational session can give them an opportunity to learn about services, clarify their concerns and plan for the future.
“Hospice is a loaded term, and I don’t take that lightly,” says Dr. Lagman. “But the stress and challenges of dealing with a life-limiting illness are daunting for anyone, and the overall support that hospice provides in these situations should be appreciated and recommended by any physician. We find that the longer patients are enrolled in hospice care, they and their caregivers reap the benefits.”
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