Rates and risks for late referral to hospice in patients with primary malignant brain tumors.
BACKGROUND
Primary malignant brain tumors (PMBTs) are devastating malignancies with poor prognosis. Optimizing psychosocial and supportive care is critical, especially in the later stages of disease.


METHODS
This retrospective cohort study compared early versus late hospice enrollment of PMBT patients admitted to the home hospice program of a large urban, not-for-profit home health care agency between 2009 and 2013.


RESULTS
Of 160 patients with PMBT followed to death in hospice care, 32 (22.5%) were enrolled within 7 days of death. When compared with patients referred to hospice more than 7 days before death, a greater proportion of those with late referral were bedbound at admission (97.2% vs 61.3%; OR=21.85; 95% CI, 3.42-919.20; P < .001), aphasic (61.1% vs 20.2%; OR = 6.13; 95% CI, 2.59-15.02; P < .001), unresponsive (38.9% vs 4%; OR = 14.76,;95% CI, 4.47-57.98; P < .001), or dyspneic (27.8% vs 9.7%; OR = 21.85; 95% CI, 3.42-10.12; P = .011). In multivariable analysis, male patients who were receiving Medicaid or charitable care and were without a health care proxy were more likely to enroll in hospice within 1 week of death.


CONCLUSIONS
Late hospice referral in PMBT is common. PMBT patients enrolled late in hospice are severely neurologically debilitated at the time hospice is initiated and therefore may not derive optimal benefit from multidisciplinary hospice care. Men, patients with lower socioeconomic status, and those without a health care proxy may be at risk for late hospice care and may benefit from proactive discussion about end-of-life care in PMBT, but prospective studies are needed.
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Eli L
EL
Diamond
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
David
D
Russell
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Maria
M
Kryza-Lacombe
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Kathryn H
KH
Bowles
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Allison J
AJ
Applebaum
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Jeanne
J
Dennis
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Lisa M
LM
DeAngelis
Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (E.L.D., M.K-L., L.M.D.); Center for Research on End of Life Care, Weill Cornell Medical College, New York, New York (E.L.D., H.G.P.); Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York (D.R., K.H.B.); Center for Integrative Science in Aging, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania (K.H.B.); Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York (A.J.A.); VNSNY Hospice Care, Visiting Nurse Service of New York, New York (J.D.).
Holly G
HG
Prigerson
D000368:Aged; D001932:Brain Neoplasms / Q000451:nursing*; D015331:Cohort Studies; D005260:Female; D006699:Home Care Services / Q000706:statistics & numerical data; D017051:Hospice Care / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors
glioblastoma; malignant brain tumor; palliative care; quality of life