Vitality

One-Third Of Elderly Veterans With Terminal Cancer Don't Recieve Hospice Care; Half Don't Get Palliative Care

Elderly vet
A new study finds that many elderly vets with terminal cancer don't get the end-of-life care recommended by many health organizations. Photo by Christopher Furlong/Getty Images

A new study published Friday in the Journal of Palliative Medicine reveals that our veterans aren’t always getting the end-of-life care they deserve.

The researchers analyzed the medical records of nearly 12,000 veterans over the age of 65 who died of cancer in 2012. From there, they looked at the type and quality of medical care the patients received in the last 180 days of their lives, either through the United States Department of Veterans Affairs (VA) or Medicaid. Both systems allowed the patients to receive hospice care, which is strictly defined as medical care and support intended for terminally ill patients and their families, but only VA patients could also receive palliative care — treatment intended solely to ease patients’ quality of life, regardless of whether their illnesses are necessarily terminal.  

They found that 71 percent of veterans across both systems received some degree of hospice care, and that 52 percent of VA patients had received palliative care. More specifically, Medicaid patients were more likely to receive hospice care for at least three days, and VA patients had the shortest median length of stay in hospice compared to Medicaid patients and VA patients who received their care from non-VA medical centers. There were also widespread differences in when palliative care was provided to patients with different types of cancer.

"Ideally, there shouldn't be any difference in timing of this care," said lead author Dr. Risha Gidwani, an economist at the VA’s Health Economics Resource Center in Palo Alto, Calif., in a statement. "Patients should receive a service based on their clinical need, not due to health-care system factors." Gidwani is also a consulting assistant professor of medicine at the Stanford University School of Medicine.

While 86 percent of veterans overall had some degree of hospice, palliative care, or both, the researchers noted that these figures still are lacking when stacked up to the recommendations made by health organizations like the American Society of Clinical Oncology, the Institute of Medicine, and the National Comprehensive Cancer Network. These organizations have recommended that palliative care be started soon after a diagnosis of advanced cancer and be an integral part of the patient’s health plan, even if the cancer isn’t life threatening at the time.

The American Society of Clinical Oncology, along with the National Quality Forum, a nonprofit organization that sets voluntary standards of patient care, have likewise recommended that terminally ill patients receive at least three days of hospice care before their death. In the current study, only 58 percent met that criteria.

"Our work indicates palliative care needs to be better integrated into standard oncological care and that there is wide variation in receipt of hospice care,” Gidwani said.

Unfortunately, our veterans may also be getting better care than most. The authors noted that the VA has strongly advocated providing hospice and palliative care, and earlier research has shown that hospice rates elsewhere are much lower. In 2013, 47 percent of Medicare beneficiaries received hospice before death, and only 11 percent of those with cancer received it during their final three days. A 2015 study found that only 67 percent of hospitals with 50 beds or more had a palliative care program by the end of 2014, and other research has shown that doctors are often reluctant to address end-of-life care with their patients.

Expanding patients’ access to that care is a goal that’s well worth fighting for, according to Dr. VJ Periyakoil, a fellow colleague of Gidwani and clinical associate professor of medicine at the Stanford University School of Medicine. Periyakoil, who is not involved with the current research, is also director of the Stanford Palliative Care Education & Training Program as well as the Stanford Hospice & Palliative Medicine Fellowship Program.

“We know that early palliative care increases both longevity and quality of life. It is really puzzling as to why patients are referred so late despite compelling data to do otherwise," she said in the same statement released by the university. "Some doctors may say that they are unsure about the prognosis and that is why they refer patients late. However, that argument does not hold water as earlier referrals are better, and at worst we would be guilty of referring a patient a little earlier in the trajectory. "

Source: Gidwani R, Joyce N, Kinosian B, et al. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. Journal of Palliative Medicine. 2016.

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