title: Understanding their options: determinants of hospice discussion for older persons with advanced illness.
abstract: BACKGROUND
  Clinicians' discussions about hospice with patients and families are important as a means of communicating end-of-life options.
  
  
  OBJECTIVE
  To identify determinants of clinicians' hospice discussions and the impact of such discussions on hospice use.
  
  
  METHODS
  We interviewed 215 patients age > or = 60 years with advanced cancer, chronic obstructive pulmonary disease (COPD), or heart failure (HF) at least every 4 months for up to 2 years. Participants provided information about their health status and treatment preferences. Clinicians completed a questionnaire every 6 months about their estimates of patient life expectancy and their communication with the patient and family about hospice.
  
  
  RESULTS
  In their final survey, clinicians reported discussing hospice with 46% of patients with cancer, compared to 10% with COPD and 7% with HF. Apart from diagnosis of cancer, the factors most strongly associated with hospice discussion were clinicians' estimate of and certainty about patient life expectancy (P < 0.001). However, clinicians were unable to anticipate the deaths of a considerable portion of patients (40%). Although patient unwillingness to undergo minor medical interventions was associated with hospice discussion (P < 0.05), a sizeable portion of clinicians (40%) whose patients reported this characteristic did not have the discussion. Clinicians' discussion of hospice independently increased the likelihood of hospice use (OR = 5.3, 95% CI = 2.3-13).
  
  
  CONCLUSIONS
  Clinicians' discussion of hospice for patients with advanced illness, and, ultimately, patients' use of hospice, relies largely on clinician estimates of patient life expectancy and the predictability of disease course. Many clinicians whose patients might benefit from learning about hospice are not having these discussions.
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Thomas
authors.forename: John R
authors.initials: JR
authors.lastname: O'Leary
authors.forename: Terri R
authors.initials: TR
authors.lastname: Fried
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001293:Attitude to Death; D032882:Comprehension; D016638:Critical Illness / Q000523:psychology* / Q000628:therapy*; D005260:Female; D017051:Hospice Care / Q000379:methods / Q000523:psychology*; D006738:Hospices / Q000379:methods; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods / Q000523:psychology; D010353:Patient Education as Topic / Q000379:methods; D010817:Physician-Patient Relations