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A terrible choice: Cancer treatment or hospice care, but not both

University of Colorado Anschutz Medical Campus

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IMAGE: Cari Levy, M.D., Ph.D., and colleagues explore the experience of concurrent treatments and hospice during end-of-life care for cancer. view more 

Credit: University of Colorado Cancer Center

Veterans Health Administration (VHA) hospitals offer something Medicare does not: In some cases, treatments meant to alter the course of a disease can be offered along with hospice care. Now Colorado researchers are looking into the costs, benefits, and experiences of veterans receiving concurrent treatment and hospice care, and experiences of the providers and staff delivering this care. Their findings may provide the basis for wider adoption of this nonstandard practice.

"Often, Medicare patients with terminal cancer and their families are given a terrible choice: You can continue treatments or have hospice care, but not both. But the VA has this unique structure where we can provide cancer therapies that are designed to be disease-modifying while also referring patients for hospice care in the community. Now Medicare is exploring the possibility of concurrent treatment and hospice, and we said, wait we've been doing this in the VA for a long time! Maybe our experience can inform Medicare's experiment," says Cari Levy, MD, PhD, investigator at the University of Colorado Cancer Center, professor in the CU School of Medicine Department of Health Care Policy and Research, and geriatrician specializing in hospice and palliative care at the Veterans Affairs Eastern Colorado Health Care System, in Aurora, CO.

Even once curing a cancer becomes unrealistic, treatments like radiation and chemotherapy may help to ease symptoms, for example by lessening bone pain or reducing tumor burden in some patients. But these treatments add cost to a patient's care, and Medicare has traditionally only allowed the initiation of hospice care after a patient decides against further treatment.

The cost analysis of concurrent care is currently under review. The qualitative analysis of community hospice and VHA providers offering care is published this week in the journal Supportive Care in Cancer. For the current study, researchers interviewed 76 providers at six different sites involved in offering concurrent cancer therapy/hospice and analyzed interviews for common themes.

One theme expressed by VA and hospice professionals was that offering the option to continue therapy while also initiating hospice care often helped patients and their families preserve hope while transitioning into end-of-life care.

"People have this association of hospice with death. If you can say let's continue all these therapies you're receiving now and add this wonderful layer of support - a 24/7 nurse, aid for bathing, social worker, etc. - that sounds great. This is a way to shepherd the transition to hospice care without the association with death," says Levy.

A second theme was that a dedicated liaison between VA and hospice care was useful to facilitate the flow of information between these two systems.

"Providing care at the VA and through hospice requires a honed relationship between the two. In our study, sometimes that liaison was a social worker and sometimes an oncologist. With great collaboration, concurrent care was more common and more successful," says first author Leah Haverhals, PhD, health research specialist at the Department of Veterans Affairs in Aurora, Colorado.

However, the study also found that hospice care providers were often unaware or even skeptical of their ability to provide hospice concurrent with cancer treatment such as radiation and chemotherapy through the VA.

"This stuff is really confusing to people. Hospices wondered, if the VA pays for treatments, am I going to get into trouble with Medicare for providing palliative care? The hospices in the community don't want to be noncompliant with Medicare guidelines. Sometimes this led to the hospice hesitating to provide their support while a patient was on VA treatment," says Levy.

Additionally, the study found that when veterans are referred to hospice provided in the community, many patients continue to want a connection with the VA system.

"I'm a palliative care physician in the VA system, and when I refer patients to hospice, I hear the oncology team and veterans saying, but, but, but... Veterans really do want to stay connected to the VA, so even if we refer them to hospice in the community, they still want that thread back to the VA. Veterans don't want to feel cut off from their providers," says Levy.

The researchers point out that the strategy of continuing therapy while starting hospice isn't appropriate for all patients. Many patients, in fact, experience additional symptoms due to cancer treatments like chemotherapy and radiation, and if therapies are not having the intended effect, there remains more benefit in the current model of ending treatment before starting hospice. However, based in part on pioneering work at the VA, Medicare and other insurance providers are starting to recognize the potential benefit, both physically and psychologically, to the model of concurrent therapy and hospice in the context of incurable diseases including cancer.

"The hope is that all of this informs the Medicare demo and that they can say you just need to provide good care to people," says Levy. "People want good care that makes them feel good."

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