The role of chemotherapy in the hospice patient. A problem of definition.

Thereis considerabledisagreement abouttheuseofwordslike palliativeor curative. In curativetherapythegoaloftreatmentis to eradicatediseasein orderto returnthepatienttohisnormalstateof health.Curativetherapymaywarrant toleratingsignificanttreatmentrelated morbidity to accomplishthisgoal. Palliativetherapywould be everythingelse.Theproblemisthatthereare atleasttwo distincttypesof palliative therapy.In somesituationstheintentof therapyis toarrestor controldiseasein an effort to prolong survival. In this situationsometreatmentrelatedmorbidity is acceptable. Thesepatientsare generallynot consideredhospice candidates. In the other type of palliative therapythe intent haschangedfrom diseasecontrol to symptomcontrol. Thediseaseis treatedonly in sofar as thiswifi reducesymptoms. In thissituationsignificanttreatment relatedmorbidity would be unacceptable.These patientsmaybecandidatesforhospice. Finally, supportive care would be treatment designedto control symptomswith no disease-directed therapy.In this situation,no treatment relatedmorbiditywouldbeacceptable, and thesepatientsareclearlyhospice candidates. The useof the term palliative has moreto do with the intentof the interventionthanthe outcome. Bulldnstatedthatinorderto qualify for the Medicarehospicebenefit the patientmust be: “unable to benefit from further aggressive(curative) therapy.”1TheMedicarecriteriaarea life expectancyof six monthsor less and an: “understandingof the palliative rather thancurativenature of hospicecare.”2 If a physician usesthe operative definition that palliative therapy precludesthe useof any therapythat might arrestdiseaseor prolong survival, hewould not considera patient an appropriatereferraltohospiceuntil chemotherapywasclearlyofno further valueandhadbeenabandoned. If heusesthedefinition thatpalliativecarefocuseson symptommanagementbutdoesnotrestrictthetreatment of diseaseif qualityoflife is improved; then, under Medicareguidelines,as long as survival is six monthsor less, the patientmay be an appropriate hospicepatientandmaystill beacandidatefor chemotherapy. Isthisevenaproblemworthdiscussing? I think it is. Therehas beena strong desire to get patientsinto the hospiceprogramsearlierin the course oftheirdisease(themediansurvivalof patientsin manyhospiceprogramsis 25 to 30 days). However, raisingthis issue is likely to exacerbateexisting controversies.