Effect of hospice care on quality indicators of end-of-life care among patients with liver cancer: a national longitudinal population-based study in Taiwan 2000–2011

This study determined that hospice care, regardless of subgroup, reduced the likelihood of a patient being admitted to an ICU by approximately 75 % (long-H vs. non-H group, OR = 0.25; short-H vs. non-H group, OR = 0.26, p < 0.001) or receiving CPR by 80 %–90 % (long-H vs. non-H group, OR = 0.21; short-H vs. non-H group, 0.09, p < 0.001). However, the short-H group was 97 % more likely to have more than one ER visit (OR = 1.97, p = 0.003), and 56 % more likely to have more than one hospital admission (OR = 1.56, p = 0.001) compared with the non-H group. These three risks were lower for patients who received hospice care for more than 1 month. In addition, no differences in the three risks were observed between the long-H and non-H groups (OR = 0.68, p = 0.453; OR = 1.07, p = 0.762; and OR = 1.29, p = 0.204, respectively) and there were no differences regarding use of anticancer therapy among the three groups.

To the best of our knowledge, the results of this study are consistent with those of previous studies: that hospice care reduces the risk of admission to ICUs and use of CPR [8, 12‐15]. Saito et al., who investigated elderly hospice patients with non–small-cell lung cancer [15], and Gonsalves et al., who examined advanced cancer patients in hospice care [14], have reported improvement in all six QIs compared with non-hospice patients. Obermeyer et al. reported that elderly hospice patients with cancer had fewer hospitalizations, ICU admissions, CPR treatments, and deaths in hospital than those not receiving hospice care; however, the researchers excluded patients receiving chemotherapy [13]. Barbera et al. reported fewer ER visits, ICU visits, and chemotherapy treatments in people receiving hospice care); however, they did not include the other three QIs [8]. One previous study indicated that Taiwanese cancer patients receiving hospital-based hospice care were significantly less likely to be intubated or require a mechanical ventilator [25].

Liver cancer is the third most common cause of death among cancers worldwide and has a high fatality rate (overall ratio of mortality to incidence: 0.93) [26]. It is the leading cause of cancer death in Taiwan (18.3 % in 2013) [27]. In this study, we found that patients with advanced liver cancer who were not receiving hospice care were likely to use ICU care (20.8 %) and receive CPR (22.6 %) in the last month of life, compared with patients who had received a short duration (6.8 % and 2.8 %, respectively) and long duration (7.3 % and 6.6 %, respectively) of hospice care. This may be because the most common causes of liver cancer death were liver-cancer-related or hepatic failure, followed by esophageal varices with bleeding, infections, and renal failure [28], which might incentivize patients to receive intensive care to control the progress or the complications of disease. However, patients who received hospice care required less ICU care and less CPR.

Hospice care is delivered mainly as an inpatient service and less as a home-based service in Taiwan. Hospice patients with advanced cancer might frequently visit ERs or be admitted to hospitals to receive services that relieve suffering. We found that patients in the short-H group had more ER visits and hospitalizations than did those in the non-H and long-H groups. There are several possible reasons for this pattern. First, the short-H group might have required more medical assistance for symptom control; second, the patients’ symptoms or their informal hospice caregivers’ skills [29] might have been improved after long-term hospice care; third, the communication between patients/their families and nurses might have improved after long-term hospice care [30]. Dudgeon et al., who enrolled patients with all types of cancer in a study assessing a palliative care integration strategy, reported fewer ER visits and hospital admissions but no significant decreases in the percentage of deaths in hospital; however, they did not examine the other three QIs [12]. A previous study investigating why Taiwanese cancer patients preferred to stay in hospital suggested that a more effective referral system be established and that home-based hospice services be provided [31]. Education could have a significant effect on EOL care [32]. Our findings suggest that EOL cancer care in Taiwan might be optimized if health care policies promoted early hospice referral programs (longer than 1 month) and education for preparing patients and families for death.

Despite increases in the use of palliative and hospice care in elderly patients with terminal illness, ethnic disparities persist [33]. Therefore, hospice care teams who understand cultural differences between Chinese and Western societies might improve EOL quality care. In traditional Chinese culture, death is a sensitive issue and people avoid mentioning it, as to do so is considered sacrilegious [34]. This might explain why there was more than one admission to an acute care hospital in the last month of life for patients in the non-H group (21.1 %), and more than one hospice ward admission in the last month of life for patients in the short-H and long-H groups (31.7 % and 26.3 %, respectively). “The fallen leaves can return to their roots” is an important traditional Chinese religious concept [35]. Therefore, dying at home has a special meaning for patients and their families in Taiwan. Dying patients in Taiwan were commonly discharged “against medical advice” from the hospital and often with artificial respiratory support (e.g., nasal cannula) to allow their families to keep the patient “alive” long enough to enable them to die at home [9]. Accordingly, if the date of discharge for the last admission was the same as the date of death [22], the patients were recognized as dying in the acute care ward or in the hospice ward (if they had been admitted to a hospice).

Although many experts recommend a hospice stay of at least 3 months to provide standard hospice services [36], the average length of hospice stay is about 1 month in the United States [37]. One previous study reported that late hospice referral could increase the risk of a major depressive disorder during the first year of bereavement [38], result in lower reported satisfaction with hospice services by family members [39], and be related to the quality of patient care received [40]. In a multicenter survey, only 1.5 % of families assessed the timing of home-based hospice referral as early and 42.0 % assessed it as late [41]. Patients who are referred to hospice care early in their disease process can benefit more easily from this care, which may improve patients’ quality of life, patient and family satisfaction, and the cost effectiveness of treatment [42]. The barriers to early referral are related to physician and patient/family attitudes as well as the reimbursement structure itself. Physician-related barriers include a reluctance to discuss hospice care because of fears about the patient’s/family’s reaction, difficulty in survival prediction, feelings of professional failure, and loss of control [43‐46]. Patient-related barriers include denial of health status, a desire to exhaust all treatment options, a negative perception of hospice care, and patient demographics [42,47]. Another challenging issue is the prediction of survival for patients with advanced cancer. To date, clinician prediction of survival is one of the most practical and commonly used temporal approaches for prognosis estimation in spite of its tendency to overestimate survival time [48,49]. Clinicians specialized in palliative care need to be proficient at prognosis to provide the best EOL care for their patients. Accurate survival prediction allows patients and their families to develop insight into their dying and thereby set realistic priorities and expectations of care.