The role of hospice care and its potential benefits — in terms of quality of life and quality of death — for men who are actually dying of prostate cancer is theoretically well understood but relatively little studied. (It is important to appreciate that hospice care is often provided in the home and does not necessarily require that a patient be moved to an actual hospice facilty.)
Bergman et al. used Surveillance, Epidemiology, and End Results–Medicare data to identify a cohort of Medicare beneficiaries who died of prostate cancer between 1992 and 2005, characterize hospice use by these patients, and compare the use of high-intensity care between those who did or did not enroll in hospice.
Their top-line results were as follows:
- 14,521 men aged 66 years and older were identified as dying of prostate cancer.
- 7,646/14,521 patients (53 percent) used hospice care for an average (median) of 24 days.
- The following were associated with a lower likelihood of hospice use
- African American ethnicity (odds ratio [OR] = 0.78).
- A higher Charlson comorbidity index (OR = 0.49)
- The following were associated with a higher likelihood of hospice use
- Having a partner (OR = 1.23)
- A more recent year of death (OR = 1.12)
- Men dying of prostate cancer and enrolled in hospice were less likely to receive high-intensity care (OR = 0.82), including intensive care unit admissions, inpatient stays, and multiple emergency department visits.
The authors conclude that, although more individuals are receiving the benefits of hospice care, the timing of hospice referral remains poor — even though men who enroll in hospice are significantly less likely to need high-intensity, acute, end-of-life care.
In a HealthDay report on Bloomberg Businessweek, it further states that “the study team found that most wait until the very end — often just a week or two before their death — before enrolling in a hospice program.” Indeed, more than 20 percent weren’t enrolled in hospice care until the very last week of their life.
Dr. Mark Litwin, the study’s senior author stated that, “It’s important that we maximize quality of life when quantity of life cannot be changed,” in a media release from the University of California, Los Angeles’ Jonsson Cancer Center. “Most men are being referred to hospice too late and that timing hasn’t changed in the last 20 years, which is unfortunate,” he added. “As cancer specialists, we should offer these patients the best quality of life that we can, and that often means offering them the best quality of death that we can give them.”
The physical and psychosocial support offered by hospice care is designed to ease the experience of dying, rather than to prolong life. However, as demonstrated in a recent study reported in the New England Journal of Medicine (albeit not specific to prostate cancer patients), hospice care may actually be associated with a survival benefit as well as quality of life benefits in some cancer patients.
Indeed, appropriate hospice use (usually over a period of rather more than 7 days) may be able to improve the quality of the last months of a patient’s life, minimize the need for high-intensity, high-cost, acute intensive care, and reduce stress on the patient and other family members. There is a significant cultural prejudice today that tells us to prolong life at all costs. This is not always in the best interests of the patient or the family once a patient is in a terminal condition. This cultural predjudice is common even among the medical profession.
“As doctors, we often don’t want to give up,” said Litwin. “We’ve sworn to help our patients and a death is a failure to us, but the optimization of life should be our goal. Sometimes survival is of such poor quality that it should not be our primary goal.”
Mark Litwin, MD, is a member of the Scientific Advisory Board of The “New” Prostate Cancer InfoLink.