Many Terminally ill Patients Not Referred for Hospice Services, Despite Meeting Eligibility Requirements

About 45 percent of terminally ill patients are not receiving hospice services, even though many are eligible for the care, Yale researchers report in the December 22 issue of Journal of Palliative Care.

“Many patients are missing out on the benefits of hospice care, which has been shown to improve the quality of life for terminally ill patients,” said Elizabeth Bradley, assistant professor in the Department of Epidemiology and Public Health at Yale School of Medicine. “The study indicates that physicians refer only 55 percent of their eligible, terminally ill patients for hospice care and that many physicians lack knowledge about basic facts concerning hospice, such as patient eligibility criteria. For instance, many physicians reported that a patient must be expected to die within 2 months to be eligible for hospice, whereas the law states one must be expected to die within 6 months to be eligible for hospice.”

Previous studies have shown that end-of-life care for patients who die in acute care can be prolonged, painful, and sometimes at odds with patients’ and families’ wishes. Recently, many efforts have been launched in the United States to improve both the quality and appropriateness of care at the end of life and some of these efforts have increasingly focused on the more frequent and timely use of hospice care, which includes palliative, rather than curative care and enhancing the quality of life for those with progressive and irreversible illnesses.

Bradley and her co-authors looked at the results of a cross-sectional, self-administered survey of 231 Connecticut physicians. The survey was used to estimate the proportion of terminally ill patients who were referred for hospice and to examine the independent effects of physician factors on hospice referral.

The survey included internists, family physicians, oncologists, pulmonologists, and cardiologists who had admitted at least 5 patients to the hospital in the preceding year. These specialties were chosen because they represent physicians who often have primary decision making responsibility for the course of care of terminally ill patients.

On average, Bradley said physicians reported referring about 55 percent of their terminally ill patients for hospice care and 26.7 percent of the physicians referred less than one quarter of their terminally ill patients.

Physicians on the study gave many reasons for not referring patients to hospice care, including patient refusal or lack of interest; family refusal or lack of interest; and the physician’s own belief that hospice care was inappropriate or inapplicable.

“We saw that physicians’ knowledge level concerning hospice, board certification, and specialty, were each independently associated with the proportions of terminally ill patients referred for hospice,” said Bradley. “One unexpected finding was that having had previous training regarding hospice care was not associated with improved knowledge of hospice or increased propensity to refer patients for hospice care. While it’s possible that specific types of training do affect physician knowledge and/or behavior, our findings reveal that physician training, as measured broadly in this study, may not influence physician knowledge regarding hospice or physician referral practices substantially.”

Bradley said the results offer valuable clues to developing interventions and educational efforts aimed at improving physician knowledge about hospice care, as well as benefit rules, which could result in increased hospice care referrals.

“The study also suggests, however, that the marketing of such educational programs may be challenging, given the finding that most physicians perceive themselves to be knowledgeable ‘enough,’ despite important gaps in knowledge,” said Bradley.

Bradley’s co-authors included Terri R. Fried, M.D. of the VA Connecticut Healthcare System and Department of Internal Medicine at Yale; Stanislav V. Kasl and Sarah M. Horwitz of the Department of Epidemiology and Public Health at Yale; Domenic V. Cicchetti, of the Child Study Center and Department of Psychiatry at Yale; and Rosemary Johnson-Hurzeler of the John D. Thompson Hospice Institute for Training, Education, and Research and The Connecticut Hospice. The study was funded by the John D. Thompson Institute and the Nathan Cummings Foundation, and the State of Connecticut Department of Public Health.

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