"This is the situation in nearly all communities, whether large or small, academic or not. Hospice is an integral part of palliative care, and palliative care has moved many of the core concepts of hospice into the hospital and sometimes upstream.

                 We fully appreciate that nearly all hospices do not cover chemotherapy, radiation, or supportive care drugs like EPO and CSFs. They simply cannot, on a per diem reimbursement of $130-150. And no one expects them too, except in special circumstances where there is an inexpensive palliative treatment that might help and could potentially be covered. Examples might be pamidronate for symptomatic malignant hypercalcemia, or a generic chemotherapy drug for symptom control. We cannot fix the medical care system by ourselves.

                 But there are and will be more programs that will cover “concurrent” palliative treatments and hospice. Aetna’s Compassionate Care Program and similar programs have an “expanded access” option that increasingly will let people enroll in hospice but not have to give up all treatment. The insurers know that they will save money by improving care at home, and that people will elect to not be in the hospital – especially the ICU – to die, if we ask them what their choices are, before the last minute or before a 2:00 am ER visit.

                 There are also positions that ASCO members can take to help the process. We can have our patients talk with hospice for an information visit when they have 3-6 months left to live. This brings the hospice team into the picture as part of the same team, lets them know the patient, and makes transitions easier.

 If we do radiation, we can switch to single or hypofractionation schemes that give just as good symptom control, at much less cost. More hospices would be willing to pay for bone metastasis treatment if it was $500 for one treatment versus $5000 for 10.

                 We can also have the “hard conversations” earlier. Data from the CanCORS study – done mostly in community settings – shows that 60% of medical oncologists prefer to not have discussions about “DNR”, advance medical directives, or hospice until “There are no more treatment options left.” This may explain why half of lung cancer patients have not had any of their doctors mention hospice 2 months before they die. That is too late, and we can do better. When we leave it to the end, with 2 weeks left to live, we risk having our patients die in the hospital from side effects of chemo or their disease without fulfilling a life review, finding spiritual and family peace, etc.

 These parts are under our control.

Thomas J. Smith MD FACP

Director of Palliative Medicine, Johns Hopkins Medical Institutions

Professor of Oncology, Sidney Kimmel Comprehensive Cancer Center

Harry J. Duffey Family Professor of Palliative Medicine