Are Patient Preferences for Life‐Sustaining Treatment Really a Barrier to Hospice Enrollment for Older Adults with Serious Illness?

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Abstract
OBJECTIVES: To determine whether patient preferences are a barrier to hospice enrollment. DESIGN: Prospective cohort study. SETTING: Fifteen ambulatory primary care and specialty clinics and three general medicine inpatient units. PARTICIPANTS: Two hundred three seriously ill patients with cancer (n=65, 32%), congestive heart failure (n=77, 38%), and chronic obstructive pulmonary disease (n=61, 30%) completed multiple interviews over a period of up to 24 months. MEASUREMENTS: Preferences for high‐ and low‐burden life‐sustaining treatment and site of death and concern about being kept alive by machines. RESULTS: Patients were more likely to enroll in hospice after interviews at which they said that they did not want low‐burden treatment (3 patients enrolled/16 interviews at which patients did not want low‐burden treatment vs 47 patients enrolled/841 interviews at which patients wanted low‐burden treatment; relative risk (RR)=3.36, 95% confidence interval (CI)=1.17–9.66), as were interviews at which patients said they would not want high‐burden treatment (5/28 vs 45/826; RR=3.28, 95% CI=1.14–7.62), although most patients whose preferences were consistent with hospice did not enroll before the next interview. In multivariable Cox regression models, patients with noncancer diagnoses who desired low‐burden treatment (hazard ratio (HR)=0.46, 95% CI=0.33–0.68) were less likely to enroll in hospice, and those who were concerned that they would be kept alive by machines were more likely to enroll (HR=5.46, 95% CI=1.86–15.88), although in patients with cancer, neither preferences nor concerns about receiving excessive treatment were associated with hospice enrollment. Preference for site of death was not associated with hospice enrollment. CONCLUSION: Overall, few patients had treatment preferences that would make them eligible for hospice, although even in patients whose preferences were consistent with hospice, few enrolled. Efforts to improve end‐of‐life care should offer alternatives to hospice that do not require patients to give up life‐sustaining treatment, as well as interventions to improve communication about patients' preferences.