AGING
March 7, 2013

The End-of-Life Shuffle

Too many dying patients are heading to the comfort of hospice care too late. Hospital profits may be one reason.

Patients are making use of hospice care more than they were a decade ago, but the reasons behind this increase may not be positive. Hospice care is end-of-life care and is designed to offer medical, psychological and spiritual support to dying patients, helping them end their lives with as little pain and as much dignity as possible.

A new study raises some questions about whether this rise in hospice use is actually beneficial to most patients, and perhaps even more importantly, whether the services offered provide the comfort and support they should.

…[D]ying patients are getting symptom control late and can't benefit as much from the psychosocial supports available were there a longer hospice stay.

The study looked at the Medicare records of 840,000 people over the age of 65, who died in the year 2000, 2005, or 2009. From 2000 to 2009 the percentage of patients using hospice care nearly doubled, while the percentage of patients who were in intensive care in their last month of life rose from 24.3% in 2000 to 29.2% in 2009. Most telling is that in 2009 over 28% of those using hospice did so for three days or less; and 40% came to the hospice after having been in a hospital’s intensive care unit.

"With this pattern of going from the ICU to hospice,” said study author Joan Teno in a statement, “these dying patients are getting symptom control late and can't benefit as much from the psychosocial supports available were there a longer hospice stay.” She adds that "For many patients, hospice is an 'add-on' to a very aggressive pattern of care during the last days of life. I suspect this is not what patients want."

The number of times patients moved from one location to another in the last three days of life – home to hospital, for example – also rose over the decade. And in the last 90 days of life, the total number of transitions patients made from place to place also rose.

The authors believe that a combination of poor doctor-patient communication and fee-for-service care incentives is behind the trends they observed in the study.

"Poor communication leading to unwanted care is epidemic in many health systems," said study author David Goodman, whose sister died during a procedure the day before she was supposed to transition to hospice. "The patterns of care observed in this study reflect needlessly painful experiences suffered by many patients, including my sister, and other friends and family members of the research team."

Teno added that the fee-for-service financial incentives may steer doctors toward using extreme measures at the end of a person’s life, rather than having a conversation with the patient and his or her family about their end-of-life wishes.

For many patients, hospice is an 'add-on' to a very aggressive pattern of care during the last days of life. I suspect this is not what patients want.

The answer to this problem? It’s certainly not simple, but transparency may be part of the solution. The authors suggest that making quality reports a matter of public record would hold medical professionals accountable for their decisions and treatment choices.

"We need to transform our health care system, from one based on fee-for service medicine for the majority of Americans, to one where people are not paid for just one more ICU day," said Teno. "Instead we need a system where doctors and hospitals are paid for delivering high-quality, patient-centered care that understands the dying patient's needs and expectations and develops a care plan that honors them.”

The study was carried out by a team at Brown University and Dartmouth College, and published in the Journal of the American Medical Association.

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