The role of the radiation oncologist in hospice decision-making and early discontinuation of palliative radiation therapy

Introduction

Palliative care is broadly defined as the relief of health-related suffering, be it physical, psychological, social, or spiritual (1). The goal of palliative care is to improve quality of life for patients and their caregivers and can be initiated at any stage of illness. Radiation therapy is an effective palliative tool for symptoms due to advanced cancer. Yet, when expected survival is short or progression of disease is rapid, palliative radiation therapy (PRT) may have limited clinical benefit for the patient, impeding end-of-life planning and potentially delaying referral to hospice. This article defines the role of PRT at the end of life, describes instances when a patient or caregiver may stop treatment, articulates the ethical issues that arise in treating patients who are eligible for both PRT and hospice care, and discusses how radiation oncologists can bridge the realms of palliative and hospice care to deliver compassionate end-of-life care.

The role of PRT at the end of life

PRT is a well-established treatment option for the management of symptoms associated with advanced and metastatic cancer (2). It is particularly effective for pain palliation from bone metastases, prevention of further neurological compromise in patients with brain or spinal cord metastases, or alleviating symptoms due to compression or obstruction by tumor (3). PRT can improve quality of life, usually with a limited treatment burden in terms of both side effects and hospital admissions (4). This can even be true at the end of life, when prognosis is limited to weeks to months, when appropriately short fractionation courses are chosen in select settings.

There are a variety of healthcare settings in which PRT can be initiated, including the outpatient setting, rapid access clinics, or the inpatient setting with a specialized radiation oncology consult service (5). To undergo PRT, patients are initially seen in consultation by a radiation oncologist. Current practice in most centers requires patients to undergo simulation, where they are imaged on a computed tomography (CT) scanner specially configured to acquire three-dimensional images used for treatment planning. Rigid immobilization may be used. Depending on treatment urgency and treatment plan complexity, treatment can start the same day as simulation, or more commonly, a few days later to allow time for a plan to be created. Palliative treatment courses can range from 1 treatment to 15 daily treatments. However, for patients near the end of life—particularly those with a life expectancy of weeks rather than months—short-course regimens should be prioritized. A single-fraction approach (e.g., 8 Gy in 1 fraction) should be considered first, followed by hypofractionation schedules of fewer than five fractions when appropriate (6). A single treatment can take as quickly as 15 minutes of the patient immobilized, lying in the same position. The dose should offer rapid symptom relief while limiting acute toxicity, particularly for patients with limited life expectancy (6). Careful consideration of treatment burden is essential, as morbidity and early discontinuation of PRT remain common challenges near the end of life (7). Symptom relief from PRT may begin during treatment or shortly after its completion, with some patients experiencing relief that lasts for weeks to months (7,8). The timing and durability of response vary depending on indication, site of treatment, and overall prognosis.

Ensuring the benefit of PRT outweighs its burden requires careful selection of dose and fractionation based on evidence-based guidelines, accurate patient assessment, and a clear, informed consent process that prioritizes shared decision-making and aligns treatment with patient-centered goals. This decision-making process should include clinical judgment regarding a patient’s physical and cognitive ability to tolerate treatment. Appropriate provider selection is essential to identify patients most likely to benefit from PRT while avoiding undue harm near the end of life. When appropriate, the clinician or a qualified physician extender should meet with the patient during treatment to review goals of care, reassess treatment appropriateness, and ensure ongoing alignment with patient priorities.

Hospice care

Hospice is a subtype of palliative care that primarily focuses on end-of-life care for patients (9). While the objective of both palliative care and hospice is pain and symptom relief, the prognosis and goals of care can be different. Palliative care, available from the moment of a cancer diagnosis, can be pursued alongside curative therapies and does not require a terminal diagnosis. Hospice is available only when life expectancy is 6 months or less and cannot be pursued alongside curative therapies.

Initiation of early hospice care is associated with increased pain control, improved quality of life, reduced healthcare cost, less aggressive care at the end of life, and decreased burden on caregivers (10). Yet, despite the benefits of early referral to hospice care, late referrals remain common (10-12). More than a quarter of patients referred to hospice are only enrolled in their last week of life (12). The median length of stay for hospice patients is only 18 days (13). This illustrates the tendency for both providers and patients to defer hospice until a point when death is imminent (13). Reasons for delayed referral to hospice include inaccurate prognosis estimates, patient/caregiver denial of prognosis, desire to exhaust all treatment options, a negative perception of hospice as “giving up”, and feelings of professional failure on the part of the provider (13). When a patient is enrolled in hospice close to the time of death, they receive fewer benefits than hospice has to offer, as hospice providers have little time to initiate effective interventions and establish deep relationships (12).

Case example

A 77-year-old woman with metastatic breast cancer on chemotherapy presents to the emergency department with a two-week history of worsening left leg pain. Her daughter, who acts as her health care proxy, states that her mother has been essentially bedridden the last 2 days due to leg pain. She is admitted to the hospital and workup demonstrates widespread bone metastasis from her breast cancer, most notably in her left femur. She is evaluated by Medical Oncology who decline to offer further treatment due to her progression of disease on systemic therapy. As she has no further curative cancer treatments available, she is offered hospice services.

The rapid progression of disease and cessation of curative cancer treatment come as a shock to the family. They are initially hesitant with decision-making but eventually agree that comfort is their main goal of care. Her pain is only minimally relieved with morphine injections and remains uncontrolled. A consultation request is placed to Radiation Oncology for evaluation of PRT for her left femur. A palliative radiation course of 10 days is offered. The family is told that if palliative radiation is pursued, the patient cannot enroll in hospice and receive PRT at the same time.

Discussion

The case described above illustrates the “forced” choice that patients may face with end-of-life care. In the following discussion, we present a framework for addressing this common challenge in the palliative care setting.

The “forced” choice

Medicare, the primary payer for hospice care in the United States through the Medicare Hospice Benefit (MHB), pays for hospice services on a capitated basis rather than a cost basis (14). With capitation, a predetermined, fixed amount of money per patient per unit of time is paid in advance to the health care provider or system for delivery of a health care service. In theory, capitation creates incentives for efficiency and cost control because by reducing the costs of a service or treatment to below the payment level and minimizing high-cost service utilization, the health care provider or system can maximize their reimbursement. However, the fixed rates of MHB do not have the flexibility to address higher cost therapies, disincentivizing the use of PRT in hospice care, particularly for low-volume hospices (13,14). Because hospices are not able to support the cost of providing PRT for patients who may benefit from it, many hospices will not accept patients who require those services.

This situation may create what feels like a ‘forced choice’ for patients and families. Patients who decide to pursue hospice must give up, not only curative-intent therapy, but also palliative treatments, such as radiation therapy, blood or platelet transfusions, and total parenteral nutrition (13,15). While patients can technically revoke hospice enrollment to pursue treatments such as PRT—at which point Medicare would cover the treatment—the decision often places an undue burden on patients and caregivers, who must interrupt access to comprehensive hospice support during that time. Many hospices cannot accommodate concurrent delivery of PRT due to financial constraints under the MHB. As a result, patients may be required to choose between hospice enrollment and certain palliative treatments. Many oncologists agree that this “all or none” dilemma artificially created by the MHB reimbursement system is outdated, especially as advancements in palliative treatment, such as shorter treatments, have been made since this system was crafted.

Improved integration between hospice services and radiation oncology departments could eliminate the systemic barriers that currently force patients to choose between palliative radiotherapy and comprehensive hospice care. Collaborative care models, such as same-day consultation, simulation, and treatment with coordinated toxicity management by hospice teams, offer a promising solution (16). Palliative radiotherapy should be part of a multidisciplinary, patient-centered care plan that emphasizes communication among providers and alignment with patient goals (16). Strengthening partnerships between hospice and radiation oncology departments would support access to both symptom-directed treatment and holistic end-of-life care.

The burden of treatment

For patients who decide to pursue PRT knowing that hospice is on the horizon, treatment burden becomes an important consideration that affects quality of life (17). Radiation oncologists should consider options to decrease the treatment burden, reflecting the patient’s life expectancy, such as shortened treatment courses. For example, when treating painful bone metastasis, one radiation treatment with minimal time (8 Gy in 1 fraction) should be considered for eligible patients as opposed to the 10-day treatment course (30 Gy in 10 fractions) described in the case example. There have been many randomized, prospective studies evaluating shorter treatment courses to treat painful bony metastases that have demonstrated there is no difference reported in pain relief or pain medication requirement (18,19).

Yet, even after reducing the expected treatment burden, physicians still have limited ability to predict survival of incurable patients (11). There is an overwhelming amount of literature that has demonstrated that less than a quarter of physician predictions regarding patient lifespans are accurate (12,17,20-22). A significant percentage of patients with advanced cancer undergo PRT within their last 30 days of life (3). Though there are a number of algorithms that can assist with calculating life expectancy, taking into consideration factors such as functional status, presence of comorbidities, mental status, and lab values, there are no standardized criteria for decision-making regarding offering PRT (12,23,24). Given physicians’ poor ability to predict lifespan, patient selection for PRT can be suboptimal with as many as half of patients discontinuing their PRT before reaching completion (11,17,25).

There are little data regarding unexpected cessation of treatment in patients undergoing PRT during end of life (26-30). Common reasons for incomplete treatment are death (29%), clinical progression (19%), and toxicity (10%) (26). In these instances, the principles of beneficence and nonmaleficence should be applied. A significant treatment burden not only violates the principle of nonmaleficence by subjecting the patient to unnecessary suffering and morbidity but also violates the principle of beneficence, as the treatment course fails to prioritize the patient’s overall well-being and quality of life within the context of their limited life expectancy. Thus, the moral imperative lies in reassessing the goals of care, ensuring it aligns with the principles of beneficence and nonmaleficence.

The goals-of-care conversation: best-practice recommendations

Radiation oncologists, as part of the interdisciplinary care team, should engage in early and ongoing discussions about prognosis, treatment expectations, and hospice eligibility in collaboration with palliative care and medical oncology. Implementing continuous, patient-centered goals-of-care discussions throughout treatment and prioritizing patient/caregiver perspective is important (31). It reduces anxiety associated with patient/caregiver decision-making and assessment if a PRT course is of low therapeutic benefit. It can be helpful for the clinician to know that while clinicians tend to define the transition period of treatment to hospice as a singular “event”, the patient/caregiver experiences it as a “process” (32). This process can be linear, cyclical, or contain troughs and peaks, with the patient/caregiver experiencing recurring emotions, including grief and anxiety. It is also important to note that the risks and benefits of a treatment may change as the clinical situation changes. It is a continuous assessment reevaluation and decision to continue treatment.

The consideration of hospice enrollment is a central element of the end-of-life decision-making process (11,33,34). Financial, cultural, family dynamics, psychosocial, and legal factors are all associated with decision-making about hospice services (35-40). Decision-making can also be influenced by levels of patient and caregiver stress, patient and caregiver perceptions of their diagnosis and prognosis, and increasing needs for care (33,34,41-44).

Radiation oncologists can help the patient/caregiver navigate this difficult time with culturally-competent, straightforward, honest, and frequent communication about prognosis, potential side effects, and expected outcomes throughout treatment (45-47). Recommendations to assist patients or their caregivers with decision-making regarding continuation of PRT include (48):

• Evaluate the role of the patient and caregiver in decision-making and their willingness to receive information;
• Assess the patient and their caregiver’s knowledge and understanding of the prognosis and the degree of uncertainty around this. The provider should also acknowledge their own limitations in knowing prognosis and be honest and forthcoming with the patient/caregiver that prognosis can change;
• Assess the patient values, goals, and fears for the future. Also take note of any health states that patient/caregiver would find unacceptable;
• Discuss the prognosis and expected outcomes for palliative radiation. This step should occur as often as necessary over the course of treatment as patient/caregiver understanding can be dynamic and evolving;
• Summarize discussions, repeat recommendations, and continue to affirm commitment to care and symptom control.

The goal of the clinician should always be to ensure that patients receive care that is most consistent with their core values, goals and preferences during serious illness (49).

Conclusions

Palliative care is a comprehensive approach to improving the quality of life for people who are living with serious or potentially life-limiting illnesses. The main goals of radiation oncologist delivering PRT is to relieve the pain and suffering and discomfort associated with an illness and to reduce patient and caregivers’ stress. There should be a focus on maintaining dignity and making patients as comfortable as possible during the time they have remaining. Navigating the delicate balance between pursuing PRT and opting for hospice care requires a patient-centered approach, clear communication, and a commitment to compassion and preserving dignity and comfort in the final stages of life.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Candice Johnstone and Michael Shing Fung Lee) for the series “Palliative Radiotherapy Column”, published in Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-25-47/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-47/coif). The series “Palliative Radiotherapy Column” was commissioned by the editorial office without any funding sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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