Clinical Guidelines Urge Early Hospice Discussion for Patients with Advanced Cancer

By Ileana Leyva, MD, Regional Medical Director, VITAS Healthcare

The American Society of Clinical Oncology (ASCO) has reviewed and upheld its 2017 consensus guideline for patient-clinician interventions and communication in advanced cancer care, with a focus on clear and empathic conversations with patients and their families throughout the illness course, from diagnosis to consideration of end-of-life care.

Cancer clinicians are advised to ensure patient understanding of prognosis and treatment options, establish clear care goals based on patient values and priorities, and initiate discussion of palliative care, including hospice care for the last six months of life, immediately following an advanced cancer diagnosis, according to the updated guideline, which was published in the Journal of Clinical Oncology in 2024.¹

Guiding patients who are living with advanced cancer through this journey to maintain hope while also clearly communicating accurate diagnostic information can be challenging for oncology clinicians. However, improving these communication skills will create a better care experience for both patients and their families. 

Summary of Recommendations from Update

ASCO first convened a multidisciplinary panel of experts in fields such as medical oncology, hospice and palliative medicine, psychiatry, nursing, communication skills, and health disparities to develop best-practice recommendations based on a systematic review of the medical literature from 2006–2016 and formalized through a consensus process.

The authors of the original report stated effective communication skills enhance the well-being of clinicians, patients, and their families². “When providers understand who their patients are, what they want from their life and their cancer treatment, and how they make decisions, patients are empowered,” they wrote.

Researchers for the 2024 ASCO Guideline Update published in the Journal of Clinical Oncology¹ offer the following recommendations:

1. Clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer.
2. Among patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services to complement existing or emerging supportive care interventions.
3. Clinicians from across the interdisciplinary cancer care team may refer the caregivers (including family, chosen family, and friends) of patients with cancer to palliative care teams for additional support.
4. For patients with advanced cancer, the Expert Panel recommends early specialist palliative care involvement, especially for patients with uncontrolled symptoms and/or quality-of-life (QOL) concerns.
5. Clinicians should refer patients with hematologic malignancies to specialist palliative care.
6. Clinicians caring for patients in early-phase clinical trials, including phase I, may refer patients to specialist palliative care to assess and address the needs of patients with advanced solid tumors.

Three Suggested Communication Strategies

Prognosis and Goals of Care

Tailor diagnostic and prognostic information to the patient’s needs, providing hope and reassurance while not misleading the patient. Triggers for discussions of prognosis and goals of care include initial diagnosis, relapse or disease progression, change in patient goals or treatment approach, and patient/family request.

• Assure the patient that as their clinician, you will do everything you can to ensure the best possible outcome. “I will do everything I can to support you.”
• Express solidarity. “I wish I had better news.”
• Avoid minimizing bad news or changing the subject. Pause. Wait for the patient’s response, then respond empathically and encourage questions.

Treatment Options

Discuss all treatment options—including clinical trials and palliative/hospice care— in a way that facilitates understanding, promotes autonomy and preserves patient hope.

• Determine whether the patient’s values and preferences have changed since the last conversation.
• Frame the treatment options in the context of these goals and priorities.
• Focus on what can be done; acknowledge uncertainty.
• Reinforce that the patient will not be abandoned. “I will continue to take care of you, whatever happens.”

End-of-Life Care

Hospice eligibility is defined by disease states. Oncology practice guidelines, for example ASCO guidelines, indicate patients who are living with advanced cancers, such as stage three and four that are metastatic and have not been responsive to first-line anti-tumor therapies, may be hospice eligible now.

Other indications include a compromised performance status of spending 50% or greater of time in a chair or bed and having disease progression through first-line chemotherapy and/or numerous symptoms such as pain, shortness of breath, fatigue, nausea.

Initiate discussion of end-of-life care preferences early in the course of incurable cancer and revisit the topic periodically.

• Introduce hospice by aligning the patient’s goals and needs with the treatments and services that hospice care provides. “I understand that you don’t want to spend any more time in the hospital, but you are scared about pain control at home. There is a group of services called hospice, covered by Medicare, that can help you stay at home and manage your pain and other symptoms.”
• Explain that with hospice, an active plan of care focuses on identifying the patient’s goals of care, wishes, and values. Then translating these into a plan of care that reflects what the patient wants, ensuring that they and their family fully understands the illness, treatments, and interventions that individualize the plan of care while optimizing quality of life. Hospice minimizes unnecessary suffering while providing whole person-, patient-, and family-centric care.
• Refer to published protocols such as SPIKES, which may be helpful in guiding end-of-life conversations. Revisit this conversation when triggers including illness progression, functional decline, increased high-intensity healthcare utilization, and/or consideration of high-risk or high-burden interventions are present.

Having honest, timely dialogue with these patients and their families allows them to make the best possible decisions for themselves.

Additional resources are available to support your conversations about end-of-life care with patients. The VITAS Goals of Care Preceptorship program offers clinicians the essential tools and techniques to facilitate meaningful and compassionate discussions with patients and their families. Learn more.

¹Sanders, J. et al. (2024). Palliative Care for Patients With Cancer: ASCO Guideline Update. Journal of Clinical Oncology. 42, 2336-2357(2024). DOI:10.1200/JCO.24.00542

²Gilligan, T. et al. (2017). Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. Journal of Clinical Oncology. 35(31):3618- 3632.

This article was originally published in 2018 and updated on August 22, 2024.