There has been an increase in hospice usage and ICU utilization over the last ten years among elderly patients, researchers from Brown University reported in JAMA. The authors added that with more late health care transitions, repeat hospitalizations, does such aggressive care really represent what patients and their loved ones really want? Probably not.

More seniors are dying with hospice care than ten years ago, the authors explained. However, a growing number of them are doing so for a very short time immediately after being in an ICU (intensive care unit). It appears that palliative care for elderly patients is often occurring only as an afterthought, rather than a properly planned part of patient care in which doctors, providers, patients and their family sit down and discuss options.

Lead author, Dr. Joan Teno, professor of health services policy and practice in the Public Health Program at Brown University, and a palliative care physician at Home & Hospice Care of Rhode Island, said:

"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."

Dr. Teno and team gathered and examined data from the Medicare fee-for-service records of over 840,000 elderly patients (aged 66+) who died in 2000, 2005 and 2009. They focused on where these people died, what kind of medical services they received during their last three months of life, and for how long.

Since 2000, hospice and hospital-based palliative care teams have become major players in the health care system - what the authors describe as "mainstream". However, after analyzing more deeply, Teno and team found that often the fee-for-service system does not fully ensure the "full measure of comfort and psychological support that hospice is meant to provide dying seniors".
  • The proportion of dying seniors who used hospice care rose from 21.6% in 2000 to 42.2% in 2009
  • However...

  • 24.3% of these patients were in intensive care during the last month of their lives in 2000. This figure rose to 29.2% in 2009.
  • 28.4% of hospice use in 2008 included patients who were there for a maximum of just three days. 40% of these patients had come in from an intensive care stay
Researchers from the Dana-Farber Cancer Institute, Boston, reported in Archives of Internal Medicine that patients with terminal cancer who are reaching the end of their lives have a better quality of life if they are not in hospital, not in intensive care, and have a therapeutic alliance with their doctor.

Aggressive care is common at many medical centers

Co-author, Dr. David Goodman, director of the Center for Health Policy Research and a professor at the Geisel School of Medicine at Dartmouth College, gave an example. His sister in 2008 had advanced cancer and died during a surgical procedure that took place the day before she was set to enter a hospice. Goodman said "aggressive care is the norm at many medical centers".

Dr. Goodman added:

"Poor communication leading to unwanted care is epidemic in many health systems. 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."

Researchers from the Dana-Farber Cancer Institute found that terminally ill cancer patients who talk with their doctor early on during their treatment about end-of-life care tend to avoid undergoing aggressive therapy.

Of all the patients, 4.6% were referred to a hospice for up to just three days before they died in 2000, this figure rose to 9.8% a decade later.

Teno said "With this pattern of going from the ICU to hospice, 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."

Among all the patients the researchers had gathered data on, the number of days spent in a hospice during the last 30 days of their life was 6.6 in 2009, from 3.3 in 2000. However, intensive care days increased from 1.5 days in 2000 to 1.8 days in 2009.

Below are some more data the researchers reported:
  • Seniors were 24% less likely to die in hospital and 11% more likely to die at home in 2009 compared to 2000
  • But...

  • 14.2% of seniors were transferred from one place to another during their last three days of life in 2009, compared to 10.3 in 2000.

  • In 2009, patients made an average of 3.1 transitions during the last three months of their life, compared to 2.1 in 2000
Vincent Mor, senior author of the report, explained that these trends reflect:
  • More repeat hospitalizations today
  • More late transitions today
  • More ICU utilization today

Reasons and recommendations

The authors believe that the increases are the result of a mix of:
  • Physician cultures varying according to regions
  • Fee-for-service care attracting financial incentives
  • Not enough communication with the patient and his/her family regarding what the goals of care are
The team found that people with cancers - diseases with the most predictable causes of death - had a much greater probability of dying at home with hospice care than those with COPD (chronic-obstructive pulmonary disease), where end-of-life is harder to predict.

The authors also noticed that there were variations in late hospice referrals between states. In Teno's home state, Rhode Island, patients had the highest likelihood of being in a hospice for the shortest periods before they died. These differences are not the result of differences in patient health, Teno emphasized, but rather differences in local medical culture regarding palliative care.

Fee-for-service reimbursements encourage doctors and other providers, for financial reasons, to opt for aggressive measures instead of sitting down with the patient and family members to develop an end-of-life care plan than takes into account their preferences. Teno said:

"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. 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. We need publicly reported quality measures that hold institutions accountable to the standard of patient-centered care for the dying."

This study provides such data, because it reveals the patterns of where, when and for how long patients receive palliative services during their last weeks of life.

Medicare rule results in more aggressive end-of-life care

In another study carried out last year by Brown University researchers, the authors explained that a Medicare rule blocks thousands of nursing home residents from receiving simultaneous reimbursement for skilled nursing facility care and hospice care at the end of life. This Medicare rule is the reason why those residents receive more aggressive treatment and hospitalization, they added.

Lead author, Susan Miller, said "This study is the first, to the knowledge of the authors, to attempt to understand how treatments and outcomes vary for nursing home residents with advanced dementia who use Medicare SNF care near the end of life and who do or do not enroll in Medicare hospice."

Written by Christian Nordqvist