NEW YORK -- Guidelines used by physicians to predict the survival of patients with lung, heart or liver disease may be flawed, and could affect terminally-ill patients eligibility for hospice care, according to a report released this week.
Restricting hospice care to those with a 'predicted' survival of under 6 months would mean that "few patients who die of these types of chronic diseases will be eligible for hospice care," explain researchers led by Dr. Ellen Fox of the Veterans Health Administration, in Washington, DC. Their findings are published in the November 3rd issue of The Journal of the American Medical Association.
Funding constraints mean that Medicare coverage for end-of-life hospice care in the United States is limited to patients with an estimated survival of less than 6 months. Physicians use specific criteria to help predict survival times in patients unresponsive to treatment.
However, Fox and colleagues note that "most patients enrolled in hospice are dying of (end-stage) cancer," which follows a somewhat predictable pattern of decline. In a study involving over 2,600 seriously ill patients, the researchers tested the validity of these criteria when it came to serious non-cancerous illness such as bronchitis, emphysema, congestive heart failure, and end-stage liver disease.
Just 2% of patients were discharged to a hospice program, the authors write. But nearly half (44%) of patients had expressed a desire to change from active treatment to palliative end-of-life care.
Using the narrowest criteria possible, the researchers identified 19 patients as most likely to die within 6 months. However, Fox told Reuters Health that "more than half of those 19 patients survived for more than 6 months." This percentage rose to 70% when the investigators used broader criteria.
The investigators conclude, therefore, that when it comes to patients with advanced lung, heart or liver disease, current criteria "are not effective in identifying (those) with a survival prognosis of 6 months or less."
Fox and her colleagues note that current survival guidelines may be effective for end-stage cancer patients, who "are often in relatively good health until a period near the end when they experience steady decline." However, the course of patients with heart, lung or liver disease is more unpredictable. These patients "tend to live for variable lengths of time in a continuous state of poor health," the authors add, "(and their) cause of death is often a relatively sudden and unpredictable event" such as infection or hemorrhage.
"Put another way, the sickest patients are not necessarily the ones who die first," the researchers explain.
Fox believes that it might be worthwhile to ease either the Medicare criteria for entry into hospice care, or to permit funding for a form of home care that emphasized the "continuity of care that is the hallmark of hospice."
In an editorial, Dr. Thomas Finucane, of Johns Hopkins Geriatrics Center, Baltimore, Maryland, agrees with Fox that current guidelines are "rarely precise enough to be useful." He notes that terminally-ill patients and their families must make the difficult and painful decision to discontinue life-sustaining treatment and switch to palliative care. However, "for many, hope persists and surrender is excruciating," he adds.
