Uniformed Services University of the Health Sciences (Dr. Arnold); Naval Hospital Jacksonville, Fla (Drs. Hayes and Sullivan) michael.arnold@usuhs.edu
The authors reported no potential conflicts of interest relevant to this article.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States government.
Hospice use is increasing, yet many enroll too late to fully benefit. While cancer patients alone are not currently tracked, the use of hospice by Medicare beneficiaries increased from 44% in 2012 to 48% in 2019.24 In 2017, the median hospice stay was 19 days.24 Unfortunately, though, just 28% of hospice-eligible patients enrolled in hospice in their last week of life.24 Without hospice, patients often receive excessive care near death. More than 6% receive aggressive chemotherapy in their last 2 weeks of life, and nearly 10% receive a life-prolonging procedure in their last month.26
Hospice care replaces standard hospital care, although patients can elect to be followed by their primary care physician.9 Most hospice services are provided as needed or continuously at the patient’s home, including assisted living facilities. And it is also offered as part of hospital care. Hospice services are interdisciplinary, provided by physicians, nurses, social workers, chaplains, and health aides. Hospices have on-call staff to assess and treat complications, avoiding emergency hospital visits.9 And hospice includes up to 5 days respite care for family caregivers, although with a 5% copay.9 Most hospice entities run inpatient facilities for care that cannot be effectively provided at home.
Hospice care has limitations—many set by insurance. Medicare, for example, stipulates that a primary care or hospice physician must certify the patient has a reasonable prognosis of 6 months or less and is expected to have a declining course.27 Patients who survive longer than 6 months are recertified by the same criteria every 60 days.27
Hospice patients forgo treatments aimed at curing their terminal diagnosis.28 Some hospice entities allow noncurative therapies while others do not. Hospice covers prescription medications for symptom control only, although patients can receive care unrelated to the terminal diagnosis under regular benefits.28 Hospice care practices differ from standard care in ways that may surprise patients and families (TABLE 227,28). Patients can disenroll and re-enroll in hospice as they wish.28
Symptom control in advanced cancer
General symptoms
Pain affects 64% of patients with advanced cancer.29 Evidence shows that cancer pain is often undertreated, with a recent systematic review reporting undertreated pain in 32% of patients.30 State and national chronic opioid guidelines do not restrict use for cancer pain.31 Opioids are effective in 75% of cancer patients over 1 month, but there is no evidence of benefit after this period.23 In fact, increasing evidence demonstrates that pain is likely negatively responsive to opioids over longer periods.32 Opioid adverse effects can worsen other cancer symptoms, including depression, anxiety, fatigue, constipation, hypogonadism, and cognitive dysfunction.32 Delaying opioid therapy to end of life can limit adverse effects and may preserve pain-control efficacy for the dying process.
