Discussions about hospice among patients with advanced cancer.

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53 Background: Timely and effective patient-clinician communication about treatment options at the end of life (EOL) is considered essential to quality care. In this study we examined the timing and nature of first discussions about hospice. We hypothesized that earlier initiation of hospice discussions would be associated with longer hospice length of stay. Methods: We analyzed data from a randomized trial of early palliative care integrated with oncology care versus oncology care alone in patients with newly diagnosed incurable lung or non-colorectal gastrointestinal cancer at the Massachusetts General Hospital (n = 350, enrolled 5/11-7/15). Analysis included patients deceased at 1 year after last enrollment (n = 259). Electronic health records were reviewed to identify first documented hospice discussion with a medical oncology or palliative care clinician. Among hospice enrollees, we tested the association of first hospice discussion with hospice length of stay, adjusting for cancer type and randomized group. We used content analysis to explore the nature of first hospice discussions. Results: Prior to death, 79.9% of patients (54% male; M age = 64 yrs [SD = 11 yrs]) enrolled in hospice. Among hospice enrollees, 8.2% had no documented hospice discussion before enrollment. Range of time from first hospice discussion to hospice enrollment was ≤7 days (40.0%), 8-14 days (12.1%), 15-30 days (13.2%) or > 30 days (34.7%). Greater number of days between first hospice discussion and hospice enrollment was associated with more days on hospice (Beta = .14, SE = .04, p < .001). Almost half of first hospice discussions involved initiation of hospice referral. Discussions that occurred early ( > 30 days before enrollment) were varied, reflecting clinician’s provision of information; discussion of future hospice use; and initiation of dialog about patient/family areas of ambivalence or concern. Conclusions: Earlier initiation of hospice discussions was associated with more subsequent days on hospice and reflected attention to patient/family informational needs, perspectives and concerns about hospice and EOL care. Research is needed to help identify and address factors that facilitate earlier discussions with patients/families about EOL care options.