Use of Hospice among Men Dying of Prostate Cancer

End-of-life care using the hospice model seeks to control pain, promote patient and family-centered care and autonomy, and address spiritual needs as death nears. Since hospice care was added as a Medicare entitlement in 1983, the proportion of Americans using hospice has seen a steady increase. Predictors of hospice use among patients with cancer include type of insurance, partnership status, education level, income level, ethnicity, sex, age, and geographic location. Because the arc of prostate cancer varies from other malignancies, with a disease that is usually longer and more varied, it is sometimes difficult to determine when the end of life is near for men with advanced prostate cancer; thus, predictors of hospice use among men with advanced prostate cancer are not well understood. Researchers recently conducted an analysis to identify patient characteristics associated with hospice use among men dying of prostate cancer. The analysis further sought to compare use of diagnostic and interventional procedures and physician visits between those who did and those who did not enroll in hospice. Results of the analysis were reported in Archives of Internal Medicine [2011;171(3):204-210]. More than one third of Americans who die use hospice care; others choose aggressive, expensive treatments at the end of life. Nearly 30% of lifetime Medicare resources are expended in the last year of life; hospice care may reduce these costs. One third of the >28,000 men in America who die of prostate cancer every year enroll in hospice. For the current analysis, researchers linked data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program and the Centers for Medicare & Medicaid Services to identify 14,521 men ≥66 years of age who died of prostate cancer between 1992 and 2005. Of those, 53% (n=7646) enrolled in hospice. In 22% (n=1699) of those who used hospice, enrollment was noted within 7 days of death. Enrollment >180 days prior to death was noted in 9% (n=717) of hospice users. Median use was for 24 days. Multivariable modeling found that African American ethnicity and higher Charlson Comorbidity Index were associated with lower odds of hospice use (odds ratio [R], 0.78; 95% confidence interval [CI], 0.68-0.88; and OR, 0.49; 95% CI, 0.44-0.55, respectively). Higher odds of hospice use were seen in men who had a partner (OR, 1.23; 95% CI, 1.14-1.32) or who died after 1992 (OR, 1.12; 95% CI, 1.11-1.14). Men dying of prostate cancer who enrolled in hospice were less likely to receive high-intensity care, including admission to the intensive care unit, inpatient hospital stays, >1 visit to the emergency department, chemotherapy, and cardiopulmonary resuscitation. In the last 180 days of life, the OR for high-intensity care was 0.82 (95% CI, 0.74-0.91); in the last 90 days of life, OR was 0.52 (95% CI, 0.48-0.57); in the last 60 days of life, the OR was 0.41 (95% CI, 0.38-0.45); and in the last 30 days of life, the OR was 0.31 (95% CI, 0.29-0.33). Study limitations cited by the researchers include restricting the sample to Medicare beneficiaries >66 years of age, not accounting for hospice costs paid out of pocket, not incorporating patient preference for end-of-life care into the analysis, use of death certificates to establish prostate cancer as the cause of death, and not examining the temporal relationship between hospice use and high-intensity care. In conclusion, the researchers summarized their findings by noting that “the proportion of individuals using hospice is increasing, but the timing of hospice referral remains poor. Those who enroll in hospice are less likely to receive high-intensity end-of-life care.”