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Aggressive Care Still The Norm For Dying Seniors

By Alvin Tran

February 5th, 2013, 4:15 PM

Although federal data show that fewer Medicare beneficiaries are dying in hospitals, new research suggests that doesn’t mean they’re getting less aggressive care in their final days.

Researchers at the Warren Alpert School of Medicine at Brown University and others reported in the Journal of the American Medical Association Tuesday that even as deaths in acute hospitals declined between 2000 and 2009, the use of intensive care units in the final 30 days of life increased, as did short-term hospice use. The rate of changes to care for these patients, such as transitions within the last three days of life, also increased.

To Dr. Joan Teno, the study’s lead author, the increased use of hospice is encouraging, but she worries about when seniors are referred to hospice.

“While there is greater access to hospice services, there’s also more ICU, more repeat hospitalizations, and more late transitions in the last three days of life,” Teno said during an interview. “The good news is that we are referring to hospice. The bad news is we’re referring to hospice in the last hours of life.”

The findings came from an analysis of Medicare claims data from a random sample of more than 800,000 seniors 66 years and older, who died in 2000, 2005, and 2009. While a 2010 report by the federal Centers for Disease Control and Prevention has looked at the patient’s location at death, researchers in this study examined beneficiaries’ medical claims for the last 180 days of life.

Hospice use at the time of death increased from nearly 22 percent in 2000 to 42 percent in 2009, the authors reported, but short stays of three days or less went from 22 to 28 percent. And four in 10 of those short stays came after time in a hospital ICU.

According to Teno, the study’s findings, particularly the increase in the number of short hospice stays following hospitalizations, suggest that aggressive care at the end of life is growing. “We really need to improve our referral patterns to make sure that people are receiving the appropriate and timely access to palliative care services at the end of the life,” she said.

Jon Radulovic, the vice president of communications of the nonprofit National Hospice and Palliative Care Organization, says the study adds to concerns about end-of-life care. “With the number of patients (in hospice) who die under seven days or less, it’s questionable whether the patient and family caregivers are able to fully benefit from the unique services that hospice offers,” he said.

With some provisions of the federal health law set to take effect in 2014, Teno sees an opportunity to hold institutions more accountable.

“The opportunity under health care reform is to really pay for quality and not pay for another day in the ICU,” she said. “Our fee-for-service system has probably resulted in overutilization of care and really, what we want to do is get the right care at the right time, for the right person, at the right location. And we want to respect the patient’s right to choose.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

7 Responses to “Aggressive Care Still The Norm For Dying Seniors”

  1. Thanks to Dr. Joan Teno for ferreting out these findings. It would be useful if the story could expand on the study’s findings on use of intensive care rather than the hospice angle. Was the ICU treatment consistent with patient and family informed preferences? Or are we still back in 1995 when the findings from the radomized control trial SUPPORT found that patient and family preferences were not known, and therefore could not be honored. I designed and led the Robert Wood Johnson Foundation’s 12-year strategy to bring palliative care in the inpatient setting. We created oases but did not, and could not, affect the broader context in the health care setting.

  2. Bob says:

    I know my brother was one of the short-timers and the hospital, a Tenet-owned facility, resisted tooth-and-nail calling in hospice, despite the fact that they DID want to get him out of the hospital and into a nursing home (which neither he nor we wanted). The social worker was very hostile to hospice.

    Finally, my sister suggested calling a good hospice directly and they went in and got him out of the hospital and home in a day, but he couldn’t speak by that time and lived only a day and a half. So yes I do not think the ICU treatment probably represents patient preference in many cases, though it may in some. (My brother had been in the ICU post-surgery (when he was expected to recover) but was in a regular room at the time it became clear he would not recover, and the hospital social worker tried to shove him off to a nursing home and was resistent to hospice suggestions.)

    I’m very grateful to the hospice that he did die at home, but wish it could have been sooner.

  3. Bob says:

    In other words, sadly I DO believe we are still back in 1995.

  4. Tom Horton says:

    My mom passed away from ALS in 2005. None of her providers ever mentioned hospice care to us, and it was not until we took my mom to the ER for difficulty with breathing that I decided to ask about it. Fortunately, the hospital had their own home health/hospice division and the social worker visited us while in the ER. When he mentioned hospice care was available to my mom months prior due to her condition, we were really upset no one had mentioned this to us earlier. Additionally, when mom’s pulmonologist mentioned Mom would have to make a decision about being on a ventilator or not, he was unwilling to answer basic questions about what the ventilation process is like and what to expect because he said “That is a personal decision and I am not comfortable influencing that decision”. It was the hospice social worker again who answered basic questions about being on a ventilator, with no opinion or bias added, and Mom made a decision not to go on a ventilator. I hope things have improved since 2005, especially the willingess of providers to educate patients regarding hospice care and answering basic questions to help them make personal choices.

  5. Killroy71 says:

    Apparently waiting for doctors and hospitals to mention the hospice alternative is like going to a car dealer for info on mass transit.

    Do ask the hospital if it has a palliative care service or coordinator, but also do your own research, don’t wait — and make sure your hospice isn’t a for-profit chain, either.

  6. amy iskander says:

    Very difficult topic of discussion that again highlights the need for advanced health directives from patients as soon as is feasible if at all possible. Here in Australia a number of patients are also unaware of the hospice and other options that may be available to them.
    My grandafther who had terminal pancreatic cancer spent most of his final months cared for at home with the help of home nursing visits (all too brief) – but this placed a lot of emotional demands and strain on immediate family. He died in ICU 3 days after admission for pneumonia – was this ideal? Maybe not necessarily, but at that stage I think my family would have been unable to cope unassisted with his illness, and he did have adequate pain relief available that hopefully helped him to feel as comfortable as he possibly could in his final hours. There is definitely a need for more case management and support to be provided to family in these instances by qualified staff.

  7. Patricia Gonzales says:

    My doctor whom I love dearly suggested hospice to me. I am 65 with cardiopathy with a very low level of my heart functioning, I have a pacemaker/defibrillator (AICD). I really freaked out. Here I am without close family and no friends. I’ve been pretty much out of any kind of social areas for several years, always in the hospital and always alone except for providers that cook, clean, etc. And don’t do that well at it except for one person in particular who had to quit due to her own health problems. From what I’ve read, and discussed with my doctor and the hospice rep who visited me at home, hospice isn’t the usual just lay home and die. I can come and go as I wish. I would have people available round the clock. It is paid for by my insurance and Medicaid. It is LIVING MY LIFE TO THE FULLEST! And if I need or want to go to the hospital, hospice is immediately revoked and I will be hospitalized for whatever reason I need. This sounded terrible at first, but if I am guaranteed revocation at any time to go to the hospital for treatment, even to be intubated, that is my choice! Gives a new perspective on true hospice. I don’t want to mention the name of the hospice company as it may not be appropriate. My dad died several days of refusing to leave his home, refusing any outside help except for my husband to do a daily run with fresh food, to clean him up, etc. before he finally was taken to the hospital and died with a few days. He wanted no part of any public aid, bureaucracy interference, etc. He was stubborn. Guess I take after him! I sincerely hope what I said will help expose the new concept of what hospice really. It’s a way to face one’s death, be it days, months, or years. But with the uptick that one can still enjoy life as much as able. I was even told that I could travel via air, etc. if I so desired.
    Glad I could share this with you out there who face hospice and choices.

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