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Research Letter |

Physicians’ Preferences for Hospice if They Were Terminally Ill and the Timing of Hospice Discussions With Their Patients FREE

Garrett M. Chinn, MD, MS1; Pang-Hsiang Liu, MD, PhD2; Carrie N. Klabunde, PhD, MHS, MBA3; Katherine L. Kahn, MD4,5; Nancy L. Keating, MD, MPH2,6
[+] Author Affiliations
1Division of General Medicine, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston
2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
3Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
4RAND, Santa Monica, California
5Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, Los Angeles, California
6Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
JAMA Intern Med. 2014;174(3):466-468. doi:10.1001/jamainternmed.2013.12825.
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Published online

Physicians often delay hospice discussions with their terminally ill patients despite guidelines recommending such discussions for patients expected to die within 1 year,1,2 but reasons for this are not well understood. Evidence suggests that physicians “practice what they preach” when counseling about health behaviors,3 although their treatment recommendations may not necessarily reflect their own preferences, with one study suggesting they recommend more conservative treatments than they might choose for themselves.4 As physicians may prefer less aggressive end-of-life care than their patients generally receive,5 physicians’ personal preferences for hospice may influence their approach to hospice discussions with their terminally ill patients.

We examined physicians’ reported preferences for hospice enrollment if they were terminally ill. We also assessed whether physicians who would enroll in hospice if terminally ill differed from others in the timing of hospice discussions with their patients.

This study was approved by the institutional review boards at all participating institutions. We surveyed physicians caring for patients with cancer enrolled in the multiregional population-based Cancer Care Outcomes Research and Surveillance (CanCORS) study.1 Informed consent was implied by physicians’ participation in the survey. Physicians indicated on a 5-point Likert scale how strongly they agreed or disagreed with the statement “If I were terminally ill with cancer, I would enroll in hospice.” They were also asked to assume that they were caring for an asymptomatic patient with advanced cancer, who they believed had 4 to 6 months to live and report whether they would discuss hospice with the patient “now,” “when the patient first develops symptoms,” “when there are no more nonpalliative treatments to offer,” “only if the patient is admitted to the hospital,” or “only if the patient and/or family bring it up.”1

Among 4488 respondents (response rate 61%), we excluded 105 who did not answer the hospice self-preference question and 15 likely trainees who graduated after 2004. Multiple imputation was used to address item nonresponse in the adjusted analyses.6

We used multivariable logistic regression to examine physician and practice factors associated with physicians’ strong agreement that they would enroll in hospice if terminally ill with cancer. In a second model, we assessed if physicians who strongly agreed they would enroll in hospice were more likely than other physicians to report discussing hospice “now” with their terminally ill patients. We omitted variables with adjusted P values >.10.

Respondents’ characteristics are given in the Table. Most respondents strongly (64.5%) or somewhat (21.4%) agreed they would enroll in hospice if terminally ill. In adjusted analyses, physicians who were female, cared for more terminally ill patients, and worked in managed-care settings were more likely than others to strongly agree they would enroll in hospice. Surgeons and radiation oncologists were less likely than primary care physicians to strongly agree they would enroll in hospice.

Table Graphic Jump LocationTable.  Physician Willingness to Enroll in Hospice: Personal and Practice Characteristicsa

Overall, 26.5% reported they would discuss hospice “now” with a patient who had 4 to 6 months to live. Other physicians reported they would wait until the patient has symptoms (16.4%), there were no more treatments to offer (48.7%), the patient and/or family brings it up (4.3%), or the patient is hospitalized (4.1%). After adjustment, physicians who strongly agreed they would enroll in hospice themselves were more likely than other physicians to report discussing hospice “now” (odds ratio, 1.7; 95% CI, 1.5-2.0) (Figure).

Place holder to copy figure label and caption
Figure.
Physician Willingness to Enroll in Hospice and Report of Early Hospice Discussions With Terminally Ill Patients With Cancer
Graphic Jump Location

Most physicians reported they would enroll in hospice if they were terminally ill with cancer, particularly women, primary care physicians, and those in managed-care settings and with more terminally ill patients. Physicians with strong personal preferences for hospice were more likely than others to report discussing hospice with their patients earlier. Physicians should consider their personal preferences for hospice as a factor as they care for terminally ill patients with cancer. Physicians with negative views of hospice may consider pursuing additional education about how hospice may help their patients.

Corresponding Author: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115-5899 (keating@hcp.med.harvard.edu).

Published Online: December 16, 2013. doi:10.1001/jamainternmed.2013.12825.

Author Contributions: Drs Liu and Keating had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chinn, Liu, Keating.

Acquisition of data: Klabunde, Kahn, Keating.

Analysis and interpretation of data: Chinn, Liu, Klabunde, Kahn, Keating.

Drafting of the manuscript: Chinn, Liu, Keating.

Critical revision of the manuscript for important intellectual content: Chinn, Liu, Klabunde, Kahn, Keating.

Statistical analysis: Chinn, Liu, Keating.

Obtained funding: Kahn, Keating.

Administrative, technical, or material support: Klabunde.

Study supervision: Kahn, Keating.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (Dana Farber Cancer Institute/Cancer Research Network [U01 CA093332], Harvard Medical School/Northern California Cancer Center [U01 CA093324], RAND/UCLA [U01 CA093348], University of Alabama at Birmingham [U01 CA093329], University of Iowa [U01 CA093339], University of North Carolina [U01 CA093326]) and by a Department of Veterans Affairs grant to the Durham VA Medical Center [CRS 02-164]. Dr Keating’s effort was also funded by grant 1R01CA164021-01A1 from the NCI.

Role of the Sponsors: Dr Klabunde is an employee of the NCI. Aside from her contributions, the funding agencies had no role in design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript

Previous Presentation: Portions of this work were presented in abstract form at the Society of General Internal Medicine’s 36th Annual Meeting; April 25, 2013; Denver, Colorado.

Additional Contributions: Robert Fletcher, MD, MSc, Harvard Medical School, provided helpful comments on an earlier version of the manuscript.

Correction: This article was corrected on January 8, 2014, to fix the value of the number of respondents reported in the Methods section.

Keating  NL, Landrum  MB, Rogers  SO  Jr,  et al.  Physician factors associated with discussions about end-of-life care. Cancer. 2010;116(4):998-1006.
PubMed   |  Link to Article
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: palliative care: version 1. 2013. http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf. Accessed May 21, 2013.
Wells  KB, Lewis  CE, Leake  B, Ware  JE  Jr.  Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA. 1984;252(20):2846-2848.
PubMed   |  Link to Article
Ubel  PA, Angott  AM, Zikmund-Fisher  BJ.  Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011;171(7):630-634.
PubMed   |  Link to Article
Gramelspacher  GP, Zhou  X-H, Hanna  MP, Tierney  WM.  Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997;12(6):346-351.
PubMed   |  Link to Article
He  Y, Zaslavsky  AM, Landrum  MB, Harrington  DP, Catalano  P.  Multiple imputation in a large-scale complex survey: a practical guide. Stat Methods Med Res. 2010;19(6):653-670.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Physician Willingness to Enroll in Hospice and Report of Early Hospice Discussions With Terminally Ill Patients With Cancer
Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Physician Willingness to Enroll in Hospice: Personal and Practice Characteristicsa

References

Keating  NL, Landrum  MB, Rogers  SO  Jr,  et al.  Physician factors associated with discussions about end-of-life care. Cancer. 2010;116(4):998-1006.
PubMed   |  Link to Article
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: palliative care: version 1. 2013. http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf. Accessed May 21, 2013.
Wells  KB, Lewis  CE, Leake  B, Ware  JE  Jr.  Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA. 1984;252(20):2846-2848.
PubMed   |  Link to Article
Ubel  PA, Angott  AM, Zikmund-Fisher  BJ.  Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011;171(7):630-634.
PubMed   |  Link to Article
Gramelspacher  GP, Zhou  X-H, Hanna  MP, Tierney  WM.  Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997;12(6):346-351.
PubMed   |  Link to Article
He  Y, Zaslavsky  AM, Landrum  MB, Harrington  DP, Catalano  P.  Multiple imputation in a large-scale complex survey: a practical guide. Stat Methods Med Res. 2010;19(6):653-670.
PubMed   |  Link to Article

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