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end-of-life care, hospice home care use, terminally ill cancer patients



  1. Tang, Siew Tzuh


Background: Despite the widespread availability of hospice services for more than two decades in the United States, currently many terminally ill cancer patients who may benefit from hospice care do not receive it.


Purpose: To identify determinants of the use of hospice home care services for terminally ill cancer patients during their final days of life.


Methods: Secondary analysis of data from 127 terminally ill cancer patients who participated in a prospective and exploratory study aimed at identifying determinants of congruence between the preferred and actual place of death. Multivariate logistic regression analysis was conducted to identify determinants of hospice home care use.


Results: Sixty-four (50.4%) out of the 127 participants had used hospice home care services before death. Important determinants of hospice home care use included: (a) longer length of survival (odds ratio [OR] 1.02; 95% confidence interval [CI]: 1.01-1.03); (b) perceived greater family ability to achieve preferred place of death (OR: 1.85; 95% CI: 1.30-2.62); (c) home as the realistic preferred place of death (OR: 5.58; 95% CI: 1.95-16.03); (d) being female (OR: 5.37; 95% CI: 1.81-15.95); (e) lower levels of functional dependency (OR: 0.94; 95% CI: 0.89-0.99); and (f) use of emergency care during the final days of life (OR: 4.03; 95% CI: 1.26-12.94).


Conclusions: The results of this study identified several groups of terminally ill cancer patients who were at a disadvantage to use hospice home care, including those without sufficient family resources but who required intensive nursing care. Providing nursing care that enables family care-taking at home may facilitate hospice home care use for patients.


Improving the quality of end-of-life care has become a major agenda for patients, families, healthcare professionals, researchers, and policy makers. In the United States (US), modern hospice care was introduced in 1974. Different from the model of hospice care in the United Kingdom, hospice care in the patient's home has been emphasized in the US. An essential goal of hospice care is to help terminally ill cancer patients remain at home in accord with their wishes and avoid unnecessary institutionalization during their final days of life (Higginson, Astin, & Dolan, 1998). Empirical evidence supports the effectiveness of hospice home care by (a) achieving terminally ill cancer patients' preference of dying at home (Dunphy & Amesbury, 1990;Grande, Addington-Hall, & Todd, 1998); and cost savings for end-of-life home care and (b) reducing high-technology interventions (Emanuel, 1996). Recently, a study conducted by Tang (2002) suggests that use of hospice home care services at the end of life facilitate the congruence between the preferred and actual place of death for terminally ill cancer patients.


The US has an ample supply of hospice programs and through Medicare, Medicaid, or other insurance programs, most people have coverage for hospice care (Friedman, Harwood, & Shields, 2002). Data have indicated a significant increase in hospice use from 1992 to 1998 (General Accounting Office, 2000;Hogan, Lunney, Gabel, & Lynn, 2001) and the availability of hospice is widespread (Virning, King, McBean, & Fisher, 2000). Despite these increases in the use of hospice care before death, there are persistent concerns that many people who could benefit from hospice care do not receive it. Current estimates of patients using hospices before death are unsatisfactory. Although not all decedents require hospice care before they die, those potential dying patients have been estimated at 40-60% of deaths (Connor, 1999;Mahoney, 1998). However, hospice care is used by a small percentage (10-15%) of elderly Americans before death (Christakis & Iwashyna, 2002;Virning, Kind, McBean, & Fisher, 2000). The rate of cancer patients' hospice use was reported as 43.4 % in 1996 (Virning, Kind, McBean, & Fisher, 2002) and 51% in 1998 (Hogan, Lunney, Gabel, & Lynn, 2001).


Research shows that patients are not likely to have equal access to hospice home care. Before the growth of hospice home care enrollment can be promoted, there is a need to identify why some patients are currently at a disadvantage to receive hospice home care. By investigating factors influencing hospice use, insight into potential increment of hospice use for cancer patients may be obtained and effective nursing interventions for overcoming the identified barriers to hospice home care services may be developed. Providing hospice home care to more terminally ill cancer patients (who may otherwise be deprived of the services) can be a strategy to achieve the preference of terminally ill cancer patients regarding the place of end-of-life care and death (Grande, Addington-Hall, & Todd, 1998). Consequently, the likelihood of congruence between the preferred and actual place of death, which is one of the major outcomes to evaluate end-of-life care interventions (Patrick, Engelberg, & Curtis, 2001), may be increased.