Hospice

Hospice is care provided at the end of life that focuses on comfort and symptom management rather than prolonging one’s life. Think quality, not quantity.

I am the medical Director for Bristol Hospice in Richmond, Virginia. Thus I have a strong positive opinion on the benefits of hospice as is a part of my normal practice, and I think it is greatly under utilize.

Doctors are generally pretty good about predicting when death is approaching. We utilize the patient’s condition, the available medical information like imaging test, labs, vital signs to inform our prognosis. Truly, in essence, it comes down to a gut feeling. The longer we think someone may have the less accurate we become. Here are a couple studies examples:

343 doctors provided survival estimates for 468 terminally ill patients at the time of hospice referral in Chicago (reference)

“Median survival was 24 days. Only 20% (92/468) of predictions were accurate (within 33% of actual survival); 63% (295/468) were overoptimistic and 17% (81/468) were overpessimistic. Overall, doctors overestimated survival by a factor of 5.3. Few patient or doctor characteristics were associated with prognostic accuracy. Male patients were 58% less likely to have overpessimistic predictions. Non-oncology medical specialists were 326% more likely than general internists to make overpessimistic predictions. Doctors in the upper quartile of practice experience were the most accurate. As duration of doctor-patient relationship increased and time since last contact decreased, prognostic accuracy decreased.”

However when time is close; accuracy goes up:

“There were 2155 questionnaires completed by 18 physicians and 1916 submitted by 15 nurses. In the 312 patients included, the 28-day mortality rates were predicted by physicians and nurses. The overall proportion of correct prognosis prediction was 90.1% for physicians and 64.4% for nurses (P = 0.000).” (reference)

I frame my prognosis in time intervals. For instance: hours to days, days to weeks, weeks to a few months.

Hospice requires a prognosis of less than six months. Even with this requirement I’ve had hospice patients last days other last years. Hospice is covered 100% by Medicare and thus they set the regulations for all of hospice care. Hospice if for those who recognize life is coming to an end and wish to focus on comfort for the time left. Symptom management on a day by day basis is the focus, not prolonging life.