Many patients with advanced cancer spend time as inpatients in the hospital, including near the end of life. When it’s time to leave the hospital, some patients are not ready to return home without support. These patients and their families must make a decision: If they qualify, should they opt for hospice care? Or, perhaps with the hope of becoming strong enough to receive further cancer treatment, should they seek a referral to a rehabilitation facility?

To help patients and their health care providers make more informed discharge decisions, social worker Louise Knight and colleagues at Johns Hopkins Hospital in Baltimore reviewed the charts of all the cancer patients discharged from the hospital to subacute rehabilitation (SAR) facilities from 2009 to 2017. This included 334 patients with advanced, metastatic or relapsed cancer and 24 patients with local disease. For most patients, discharge to an SAR facility was not a bridge to cancer treatment, the researchers report in the October 2019 issue of Journal of Oncology Practice.

While some patients recuperate during rehab, “the majority of patients don’t do so well. They die soon after leaving the hospital and don’t have a chance to get further cancer treatment,” says Jonathan Yeh, a fellow in hospice and palliative medicine at Johns Hopkins who co-authored the paper.

Of the 358 patients referred to SAR during the study period, two-thirds had not received further cancer treatment by May 2018, when the researchers stopped collecting data. Further, 21% of patients died within 30 days of their discharge and of those, only 31% received hospice services.

“In an ideal world, all of these patients should have had hospice following them, potentially, if they had such a short life expectancy, but for our group, it was the minority that had hospice following them,” says Yeh.

The rise of immunotherapy drugs in the past decade may contribute to patients’ desire to pursue further treatment, the researchers suggest. However, they found that just three patients who had not already been receiving immunotherapy were able to start it after opting for SAR.

Rehab Versus Hospice

A patient’s medical team, physical therapists and, of course, the patient herself jointly make decisions about hospital discharge, Yeh says. Those who are too weak to return home safely after leaving the hospital may be referred to acute or subacute rehabilitation. In an acute rehabilitation facility, Yeh says, patients receive three or more hours of physical, occupational or speech therapy per day, while in SAR facilities, patients receive less than three hours of daily therapy.

Some patients may seek rehabilitation in order to gain the strength to receive further cancer treatments. Additionally, if a patient has complications during treatment, she may need to pause treatment and go to rehab to gain the strength to continue, Yeh says.

Alternatively, a patient may enroll in hospice, which is care for seriously ill patients who are expected to live six months or fewer. It can take place in an inpatient facility, but most often hospice, which Yeh calls more of a philosophy than a physical place, takes place in the home. Medical professionals focus on providing patients with symptom relief but do not attempt to treat their cancer. Aides visit regularly to help patients with tasks like bathing and grooming, while social workers and chaplains are available to help with emotional and spiritual needs. The patient and her family have access to 24-hour phone support through a hospice agency.

In hospice, patients may undergo some physical rehabilitation, but it is most likely limited to helping the patient do things that will make them more comfortable, such as gaining the strength to use a bedpan or to roll over in bed, says Yeh. When patients are dying, their strength wanes. For that reason, physical rehabilitation and hospice “are not totally compatible,” says Yeh. Patients considered too weak to return home to recuperate may be able to return home for hospice, Yeh says.

Hospice can also be an insurance benefit, paid for by Medicare or private insurance, to cover end-of-life care, Yeh adds. A patient qualifies for hospice after a physician certifies that she has six months or fewer left to live if her illness follows its typical course. Once a patient has enrolled in hospice, insurers typically stop covering life-prolonging treatments. Rehabilitation, as provided in an SAR, also typically cannot be covered once a patient has enrolled in hospice, Yeh says.

The findings of the new study are similar to those from a 2017 study​ on patients with progressive metastatic gastrointestinal cancer discharged to SAR. Of 22 patients admitted to the Gastrointestinal Medical Oncology Service at Memorial Sloan Kettering Cancer Center in New York City and discharged to SAR between 2008 and 2014, 32% died at the SAR facility and none lived more than six months after discharge from the hospital. Fewer than half received hospice services within three months of discharge. None received further chemotherapy.

Because SAR facilities tend not to have palliative care and pain control experts, which hospice care does provide, “there many have been a detriment incurred by an SAR discharge that a hospice discharge may have avoided,” the authors write.

Roots of the Problem

Doctors tend to avoid talking to patients about hospice because it can be difficult to be the bearer of bad news, Yeh says. Further, cancer patients today are so used to facing challenge after challenge that they tend to expect to recover. “This conversation about subacute rehabilitation services becomes the next bump in the road,” Knight says. “The question really becomes, and you can see how complicated this is: How do you know that this is the one bump that you can’t get over?”

Knight and her colleagues did observe some significant differences between the patients who received further therapy after discharge to SAR and those who did not. Patients who received cancer treatments after SAR were significantly more likely to have local disease, to have leukemia or lymphoma, as opposed to a solid tumor, and to have been receiving cancer therapy at the time of discharge to SAR. “We can use some of these characteristics to guide our conversations with patients. Is it 100% predictive? Not necessarily, but I think it’s certainly a start,” says Yeh.

“I think that the most important thing that we’re underscoring here is the importance of having a very honest discussion with patients about their prognosis,” Yeh says, as well as conversations informing patients about what typically happens to cancer patient discharged to SAR.

With this knowledge, some patients will still want to go to rehab to increase their chances of recovery, while others, knowing the chances of receiving further treatment are low, might decide against rehab, Yeh says. “It’s not necessarily that we should just avoid rehab altogether; it’s not necessarily that everyone needs to go to hospice right away. It’s just that these are some very important conversations that I don’t think we’re having enough of.”​​ 

Ashley P. Taylor is a writer and science journalist based in New York City.​