| The hospice Medicare benefit and many state
statutes often refer to 'terminal patients' defined as patients with incurable diseases
and a life expectancy of six months or less. There is little evidence that physicians can
make accurate survival predictions and little agreement as to what defines a 'terminal
period' and almost no data that would suggest this period lasts six months. Using data from the National Hospice Study and graphing declining Karnofsky score by month leading up to death along with rising health care costs, it is clear that (at least for cancer) patients do not show a rapid physical decline until about four months prior to death, and that a period of extremely poor health with intensive need for support, lasts only about two months prior to death. It is probably no surprise that the average survival of hospice patients is around 60 days. (figure 1) Patients diagnosed with incurable cancer sometimes equate such a diagnosis with being terminal. Many patients with incurable cancer live many months and even years as noted in figure 2 and figure 3. Some general guidelines and survival expectations are noted in the tables: survival with advanced cancer, and survival with brain metastases. Patients have a legal and ethical right to accurate information and physicians should endeavor to provide the information the patient requests. Most patients desire to know if they are in jeopardy but few actually want the physician to speculate on a specific life expectancy. Physicians are obviously not required to provide information that that they don't have, but if a patient is persistent in their request for some general idea on life expectancy, the physician should try to provide an accurate range. Most patients are not well served by euphemisms (e.g. "only the Man upstairs knows for sure...") Hospice advocacy groups are working with HCFA to revise the Medicare guidelines to make them more appropriate. |