Aggressive care faulted for delayed moves to hospice

Efforts to exhaust all treatment options before transitioning to palliative care may deprive patients of the full range of hospice services, says a JAMA study.

By Charles Fiegl amednews staff — Posted Feb. 18, 2013

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Even though use of hospice services has increased among the elderly and disabled, physicians are concerned that too many patients are beginning palliative care just a few days or even hours before dying.

Researchers found a trend of increases in two types of burdensome hospice care transitions, according to a study in the Feb. 6 Journal of the American Medical Association. A larger portion of patients are being referred for hospice services during the last three days of life, and a larger portion are being admitted to the hospital multiple times in the last 90 days of life.

The percentage of beneficiaries who had hospice services before dying nearly doubled from 2000 to 2009, a trend palliative care experts found to be a positive development. However, 28.4% of decedents were in hospice care for three days or less in 2009, up from 22.2% in 2000, and 11.5% had been hospitalized three or more times during the 90 days before death, an increase from 10.3%, the authors stated.

The study suggests that a significant number of beneficiaries and their families are not receiving the full benefits of hospice care because the transition to palliative care occurs too late, said Joan Teno, MD, an author of the study and professor at the Alpert Medical School of Brown University in Rhode Island. She also is associate medical director of Home and Hospice Care of Rhode Island.

The appropriateness of a hospice referral is a decision that needs to be based on patient preferences, Dr. Teno said. From a clinician's standpoint, patients who transfer to hospice three days or less before dying do not receive the full range of services available.

“You don't get the team on psychological support or get closure to help the patient and family with one of the saddest moments of their life,” Dr. Teno said. “You often need more than 12 hours for a complex intervention.”

American Medical Association policy recognizes the benefits of hospice to patients and their families. Physicians have a responsibility to see hospice services are authorized during appropriate circumstances and settings, according to the AMA.

Patient, family reluctance a factor

The Medicare hospice benefit covers patients who are enrolled in the Part A hospital benefit who receive a physician certification statement declaring that the patient has a terminal illness and six months or less to live.

Hospice advocates had hoped that awareness and increased use of hospice and palliative care would reduce patterns of aggressive medical care toward the end of a patient's life, Dr. Teno and her co-authors stated in the JAMA article. “However, our findings in a population of fee-for-service Medicare beneficiaries do not bear this out.”

For instance, the proportion of beneficiaries who stayed in an intensive care unit during the last month of life increased to 29.2% in 2009 from 24.3% in 2000.

Seventeen percent of hospice patients spent three days or less under the care of the Center for Hospice Care in South Bend, Ind., in 2012, said Mark Murray, the center's president and CEO. One out of 16 referrals died in a matter of hours, before the center could pick up the patients.

Nearly 30% of Medicare beneficiaries were treated in an ICU in the last month of life.

“It has been a big problem and a big issue for us,” Murray said.

Many patients and their families want to exhaust all treatment options before considering hospice, he said. However, this leads to patients missing out on palliative care that could improve quality of life during their final months with their families.

“For years the hospice community has been concerned about the growing number of patients who come to hospice within days or hours of dying,” said J. Donald Schumacher, president and CEO of the National Center for Care at the End of Life. “A part of this issue involves patients and families not being aware of the full range of care options available — that would include hospice — when coping with a serious, life-limiting illness.”

Data compiled by the hospice association conclude that about a third of hospice patients died or were discharged within a week to 10 days of a hospital admission, Schumacher said. Some patients and families are reluctant and still wanted to pursue medical interventions. But the 5,000 hospices in the U.S. believe the lengths of stay in palliative care will increase once more people come to know about hospice care and the services available, he said.

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Hospice, aggressive care up for Medicare patients

Researchers reviewed a random 20% sample of Medicare patients who died in 2000, 2005 and 2009. Their analysis showed growing use of hospice services but also higher use of care in a hospital ICU at a time close to death.

Category 2000 2005 2009
Decedents 270,202 291,819 286,282
Deaths in acute care hospitals 32.6% 26.9% 24.6%
ICU use in last month of life 24.3% 26.3% 29.2%
Hospice use at time of death 21.6% 32.3% 42.2%
Transitions in last 90 days of life per decedent (mean) 2.1 2.8 3.1
Health care transitions in last three days of life 10.3% 12.4% 14.2%

Source: “Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 200, 2005 and 2009,” The Journal of the American Medical Association, Feb. 6 (link)

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External links

“NHPCO Facts and Figures: Hospice Care in America,” National Hospice and Palliative Care Organization, 2012 (link)

“Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 200, 2005 and 2009,” The Journal of the American Medical Association, Feb. 6 (link)

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