Advance Care Planning, Hospice Eligibility, Hospice Basics
April 11, 2016

Earlier Hospice Enrollment Key to Higher Family Ratings of Care Quality

Patient caretaker smiling at healthcare professional

Improving Quality of Care

Family members were more likely to rate their loved ones’ end-of-life care as “excellent” when patients were enrolled in hospice for longer than three days, died outside of the hospital and were not admitted to an intensive care unit (ICU) within the final month of life. This is according to a report on a family-interview-based study published in a special Death and Dying issue of the Journal of the American Medical Association.

“Our findings suggest that efforts to increase early hospice enrollment and avoidance of ICU admissions and hospital deaths might improve the quality patient and family member centered end-of-life care,” write the authors of the report. “To our knowledge, this study is one of the first empirical validations of these aggressive end-of-life care indicators using patient-and family-member-centered outcomes in a population-based cohort.”

Investigators analyzed Medicare claims data linked to interview responses of 1,146 family members of older patients (median age, 76.0 years; male, 55.8%) who had died of colorectal or lung cancer by the end of 2011. Patients were participants in the Cancer Care Outcomes Research and Surveillance (CanCORS) study, a multiregional, prospective and observational study of patients newly diagnosed with cancer from 2003 through 2005. Participating family members were interviewed a median of 144.5 days following the patient’s death.


  • 51.3% of family members assessed their loved one’s end-of-life care as “excellent;” 27.8% as “very good”; and 20.9% rated care as either “good, fair or poor.”
  • Only 56.7% of patients died in their preferred place.
  • 18.9% of family members reported that the end-of-life care was only “somewhat” or “not at all” consistent with patients’ wishes, while 81.1% indicated that patients’ wishes were followed a “great deal.”

Higher Ratings with Earlier Hospice:

  • Care was deemed excellent more often for patients who received > 3 days of hospice care compared with those who had received no hospice or had been enrolled for ≤ 3 days (58.8% vs 43.1%; adjusted percentage point difference, 16.5 points).
  • Respondents whose loved ones received hospice care for > 3 days were more likely to report that the patients had died in their preferred location than were those whose loved ones received no hospice or were enrolled for ≤ 3 days (72.8% vs 40.0%; adjusted difference, 34.4 points).
  • Family members of patients who died while hospitalized were less likely to report the death as excellent than were those whose loved ones died outside of the hospital (42.2% vs 57.4%).
  • Respondents were also less likely to rate the patient’s care as excellent if their loved one had been admitted to an ICU within the last 30 days of life (45.0% vs 52.3%).
  • In addition, patients admitted to an ICU during the last month of life were less likely to die in their preferred place than were those with no ICU admission (38.0% vs 59.2%).

According to a joint statement from the American Society of Clinical Oncology and the National Quality Forum, note the authors, key indicators of poor quality and overly aggressive end-of-life care include: repeated hospitalizations; emergency department visits or ICU admission within the last month of life; chemotherapy delivered within two weeks of death; and late or absent referrals to hospice care.

“Patients with advanced-stage cancer receive aggressive medical care at the end of life, despite increasing evidence that high-intensity treatments may not be associated with better patient quality of life, outcomes or caregiver bereavement,” write the authors. In addition, “ICU admissions and late hospice enrollments are increasing over time.”

Because their study found that the three factors most strongly associated with an “excellent” rating of a loved one’s death by a bereaved family member were early enrollment in hospice, avoidance of ICU admission in the last month of life and avoidance of hospital death, the authors suggest that these would be three areas to target to improve the end-of-life experiences of patients and their families.

“Our study findings are a powerful argument for the importance of advance care planning,” says lead author Alexi Wright, MD, MPH, a gynecological oncologist at the Dana Farber Cancer Institute and assistant professor of medicine at Harvard Medical School. “The more information patients have, the more likely they are to receive the kind of medical care they want near death. And patients’ deaths influence family members’ perceptions of their quality of care.”

Source: “Family Perspectives on Aggressive Cancer Care near the End of Life,” Journal of the American Medical Association; January 19, 2016; 315(3):284-292. Wright AA, Keating NL, Ayanian JZ, Chrischilles EA, Kahn KL, Ritchie CS, Weeks JC, Earle CC, Landrum MB; Department of Medical Oncology, Dana-Farber Cancer Institute; Department of Health Care Policy, Harvard Medical School; and Division of General Medicine, Brigham and Women’s Hospital, all in Boston; Institute for Healthcare Policy and Innovation, Division of General Medicine; Department of Health Management and Policy, School of Public Health; and Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor; Department of Epidemiology, College of Public Health, University of Iowa, Iowa City; Rand Corporation, Santa Monica; Division of General Internal Medicine, University of California, Los Angeles; and Division of Geriatrics, Department of Medicine, University of California, San Francisco, all in California; and Institute for Clinical Evaluative Sciences, Toronto, Ontario.


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