David J. Casarett, MD, MA; Timothy E. Quill, MD
Acknowledgments: The authors thank Gretchen Brown, True Ryndes, and Drs. Barry Kinzbrunner and Perry Fine for their comments and suggestions.
Grant Support: Dr. Casarett is the recipient of an Advanced Research Career Development Award from the Department of Veterans Affairs, a Paul Beeson Faculty Scholars Award in Aging Research, and a Presidential Early Career Award for Scientists and Engineers.
Potential Financial Conflicts of Interest: Grants received: D.J. Casarett, T.E. Quill (Aetna Foundation); Other: D.J. Casarett is the Director of Research for Penn Home Care and Hospice Services, University of Pennsylvania Health System, Philadelphia, Pennsylvania, and T.E. Quill is the Director of the Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center, Rochester, New York.
Requests for Single Reprints: David Casarett, MD, MA, 3615 Chestnut Street, Philadelphia, PA 19104; e-mail, email@example.com.
Current Author Addresses: Dr. Casarett: 3615 Chestnut Street, Philadelphia, PA 19104.
Dr. Quill: University of Rochester School of Medicine, PO Box 601, 601 Elmwood Ave, Rochester, NY 14642.
Hospice programs offer unique benefits for patients who are near the end of life and their families, and growing evidence indicates that hospice can provide high-quality care. Despite these benefits, many patients do not enroll in hospice, and those who enroll generally do so very late in the course of their illness. Some barriers to hospice referral arise from the requirements of hospice eligibility, which will be difficult to eliminate without major changes to hospice organization and financing. However, the challenges of discussing hospice create other barriers that are more easily remedied. The biggest communication barrier is that physicians are often unsure of how to talk with patients clearly and directly about their poor prognosis and limited treatment options (both requirements of hospice referral) without depriving them of hope. This article describes a structured strategy for discussing hospice, based on techniques of effective communication that physicians use in other “bad news” situations. This strategy can make hospice discussions both more compassionate and more effective.
Table 1. Factors That Are Associated with a Limited Prognosis and That Should Trigger Consideration of Hospice in Selected Diagnoses*
Table 2. Useful Language for Hospice Discussions
Table 3. Hospice Services and Interdisciplinary Hospice Team Members
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Christian Medical College and Hospital
March 20, 2007
Hospice Neglected in India
The debate on end-of-life care and hospice is just beginning in India. In a survey of doctors training during residency, it was seen that participants felt their palliative care training was inadequate and concluded that palliative care training should form an integral part of training during residency.1 Unfortunately, there are only four medical colleges in the country which have some palliative care undergraduate training.2 In India, there are 138 organizations providing hospice and palliative care services to over a billion population. Most of the hospices are only for cancer patients but a minority care for people with AIDS, TB or other life limiting illnesses.3 Palliative care services in India have to serve high-density populations, the majority of whom are living in impoverished circumstances. Some of the challenges for the development of hospice and palliative care services in India are "“ poverty, geographical distances (reaching rural communities), population density, low indices of nutrition and health, low levels of literacy, low status of women, cultural perceptions of cancer; HIV/AIDS, lack of funding for the services, no state-sponsored social security system or effective medical insurance scheme, lack of awareness of palliative care within the population, opiophobia, late presentation of illness, psychosocial needs neglected in busy, over-loaded clinics, limited open communication between patient, family and health professional, disclosure of diagnosis to the patient , lack of palliative care awareness within the health professions, absence of palliative care in medical curricula, multiple & competing health systems, reimbursement for medical and health staff, growing need for measures of quality assurance in palliative care, limited research because of lack of resources (time, finances, knowledge, motivation) A characteristic of the palliative care services that is developing in India is the increasing number of home care services as most of people prefer to live and die at home and the strong family structure makes it possible.4
1. Mohanti BK, Bansal M, Gairola M et al. Palliative care education and training during residency: a survey among residents at a tertiary care hospital. The National Medical Journal of India. 2001;14:102-104.
2. Velayudhan Y, Ollapally M, Upadhyaya V et al. Introduction of palliative care into undergraduate medical and nursing education in India: A critical evaluation. Indian Journal of Palliative Care. 2004;10:9-14.
3. Chandra P, Jairam KR, Jacob A. Factors related to staff stress in HIV/AIDS related palliative care. Indian Journal of Palliative Care. 2004;10:2-8.
4. Vijayaram S. India: status of cancer pain and palliative care. Journal of pain and symptom management. 1993;8:421-422.
Michael J. Germain
baystate medical center
March 26, 2007
Hospice in dialysis patients
Carsarett and Quill describe excellent strategies for discussing hospice and supportive (palliative) care with patients and families, including how to overcome the barriers to such discussions (1). Absent from Table 1 is a common condition with a rising incidence and worse mortality than the other conditions listed, end-stage renal disease (ESRD). Incident dialysis patients have a one-year mortality of 20-30% (2). The median survival for patients > 80 years old starting dialysis is 15.6 months; this is 1/5 of the survival of a non-ESRD age-matched cohort (3). Murray et al (4) have demonstrated an alarming underutilization of hospice in this population (14% of all ESRD deaths). Only 40% of patients who stop dialysis (mean survival 8 days) die with hospice care. Carsarett and Quill discuss the regulatory barriers to hospice care, some of which in their words are "arguably unethical." ESRD patients face even more extreme barriers. Despite the recent study (4) that demonstrates a cost savings for dialysis patients who die with hospice care, interpretation of the Medicare hospice benefit by CMS, their carriers, and the hospices themselves sometimes severely restricts access for this suffering population to hospice.
1. Cassaret DJ, Quill TE. "I'm not ready for hospice": Strategies for timely and effective hospice discussions. Ann Intern Med. 2007;146:443- 449.
2. US Renal Data System. USRDS 2006 Annual Data Report: Atlas of end- stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2006.
3. Kurellla M, Covinsky KE, Collins AJ, Chertown GM. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med. 2007;146:177-183
4. Murray AM, Arko C, Chen S-C, Gilbertson DT, Moss AH. Utilization of hospice in the United States dialysis population. Clinical J Am Soc Nephrol. 2006;1:1248-1255.
Syracuse VA Medical center
April 20, 2007
Is there a difference between palliative and hospice care philosophy
To the Editor: Casarett and Quill (1) in their discussion of second case describes as if hospice care and palliative care are two different focus of care which benefit (services) wise may be true but as for philosophy of care wise is not. Both palliative care and hospice care has the same philosophy of care i.e., both attends to the physical and emotional suffering of patients with advancing conditions and the families of those patients. The only difference is that we designate or certify someone as hospice care if their life expectancy is less than six months. For palliative care life expectancy does not need to be less than six months. Benefit wise hospice and palliative care differ. Hospice care is provided through an interdisciplinary team, and patients receives additional services like home health aide and chaplain services, and their families receive bereavement counselling for at least a year after the patient's death. In palliative care insurance carriers do not provide these unique benefits that are provided through hospice. Palliative care teams in the academic settings are increasingly utilizing interdisciplinary team approach, and this is seen even more in the nursing home settings.
As for negative perception of hospice enrollment as giving up, it may also be due to delayed discussion and referral for hospice care. Likely delayed referrals are the reason for the median length of stay of three weeks in the hospice program which in turn is being seen by patients and their families as a program where someone die soon after their enrolment. Hospice discussion should be early and may be as soon as possible when curative treatment is not possible or desired by the patient and life expectancy is less than six months. Early discussion can promote more timely hospice enrollment and may improve the perception as then the median survival of patients enrolled in hospice may improve from three weeks. Early referral may improve satisfaction with end of life care as then patients and their families can benefit more from the services provided through hospice benefits.
References: 1. Casarett DJ, Quill TE." I'm not Ready for Hospice": Strategies for Timely and Effective Hospice Discussions. Ann Intern Med.2007; 443-49.
nter for Health Equity Research and Promotion, University of Pennsylvania
May 3, 2007
We fully agree with and appreciate the important comments by Germain and colleagues, and regret not including this important group of patients who could potentially benefit from hospice.
David Casarett MD MA Center for Health Equity Research and Promotion Philadelphia VAMC Division of Geriatric Medicine University of Pennsylvania
Mailing address: 3615 Chestnut Street Philadelphia, PA 19104
Contact: firstname.lastname@example.org Phone: 215 898 2583 Fax: 215 573 8684
May 15, 2007
Re: Hospice Neglected in India
You have very well taken this issue. Most of the professors, even in the Medical Colleges, have no concept regarding this. Atleast some body has taken this issue.
May 17, 2007
I must congratulate Dr. Akashdeep for highlighting the issue of hospice-a really neglected issue in India. In the corporate world, the basic intention is to fetch money. I know of many corporate hospitals where even dead patients are put on mechanical ventilation to fetch money.
Casarett DJ, Quill TE. “I'm Not Ready for Hospice”: Strategies for Timely and Effective Hospice Discussions. Ann Intern Med. ;146:443–449. doi: 10.7326/0003-4819-146-6-200703200-00011
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Published: Ann Intern Med. 2007;146(6):443-449.
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