Better Studies Needed to Dispel Confusion Over When to Refer a Patient to Hospice


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Until we have better studies to identify when it’s the right time to refer a patient to hospice, I believe it’s best to let the patient and her doctor make that decision.

—Armando Armas, MD

I read the article on “Private Payer and Academic Center Data Capture Inappropriate Use of End-of Life Care” (The ASCO Post, December 15, 2014, page 11). The data highlight Dr. Deborah Schrag’s notion that there is “ample evidence of overuse of intensive care at the end of life.” However, there is a flaw in the argument that there is overuse of intensive care at the end of life.

In real life, we never know when a patient will die or live on in response to a therapeutic intervention. Studying retrospective data that includes only deceased individuals and deriving conclusions from this information are not statistically or ethically valid. To prove that there is “ample evidence of overuse of intensive care at the end of life,” you need to do a prospective study looking at whether or not intensive care of a critically ill population of similarly matched cancer patients vs hospice care yields worse results as measured by endpoints of quality of life and extension of life-years.

The problem is that given the broad spectrum of tumor heterogeneity, it’s difficult to predict which patients with cancer will respond favorably to therapy. As often is the case, these patients are immunocompromised and often become septic. Many will die despite intensive care, but many will live to survive many months to years. By counting only the patients who died and not counting those who survived in the data, you do an injustice to the survivors, health-care workers, and future potential survivors.

We need better-designed studies before we continue to propagate the notion that any cancer patient who suffers a drawback during therapy should immediately be referred to hospice. Clearly, there are situations when the patient should be referred to hospice. Until we have better studies to identify when it’s the right time to refer a patient to hospice, I believe it’s best to let the patient and her doctor make that decision. Flooding the journals with skewed studies and constantly second-guessing health-care providers are only adding to the confusion families and patients experience every day and could lead many otherwise hopeful patients to throw in the towel prematurely. It may also cause patients to lose faith in their providers. ■

—Armando Armas, MD
Valley View Hospital
Glenwood Springs, Colorado

Disclaimer: This letter represents the views of the authors and may not necessarily represent the views of ASCO.

 



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