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Hospice use is up for dying elderly patients, but so is needlessly aggressive hospital care

hospital bed
CC/Flickr/bennylin0724
Although more terminally ill people over the age of 65 are dying in hospice care, more are also being treated aggressively — and repeatedly — in hospital intensive care units (ICUs) during the final 30 days of their life.

When surveyed, Americans tend to say they would prefer to die at home rather than in a hospital. And an increasing number of them are doing just that. According to the U.S. Centers for Disease Control and Prevention [PDF], 24 percent of people over the age of 65 died at home in 2007, up from 15 percent in 1989.

So it’s not surprising that the use of hospice services among terminally ill older Americans has also risen significantly over the past decade. Some 42.2 percent of Medicare patients received hospice services in 2009 compared to only 21.6 percent in 2000, according to a new study published Wednesday in the Journal of the American Medical Association (JAMA).

But do those trends mean fewer older Americans are receiving needlessly aggressive end-of-life hospital care?

Not necessarily. The JAMA study also found that although more terminally ill people over the age of 65 are dying in hospices, more are also being treated aggressively — and repeatedly — in hospital intensive care units (ICUs) during the final 30 days of their life. Often, they are transferred to a hospice just a day or two before they die.

“Our results confirm the previous CDC report that more people are dying at home and people are less likely to die in an acute-care hospital,” said the report’s lead author, Dr. Joan Teno, in a video that accompanied the release of the study. “But our results raise concern about the pathway that people take to dying at home.” Teno is a palliative care physician and professor of health services, policy and practice at Brown University.

For the study, Teno and her colleagues analyzed the Medicare data of a random sample of about 850,000 older Americans (aged 66+) who died either in 2000, 2005, or 2009. Before they died, all had been diagnosed as being in the terminal stages of a chronic disease, such as cancer, chronic pulmonary disease or dementia. The researchers examined where these patients died, what kind of medical care they received during the last three months of their lives, and for how long.

The analysis revealed the following trends from 2000 to 2009:

  • The rate of Medicare patients receiving care in a hospital ICU during the last 30 days of life increased by 23 percent.
  • The rate of transitions from one institution to another that the patients had to make during the last 90 days of life (for example, from nursing home to hospital or from hospital to hospice) increased by 48 percent.
  • The percentage of patients who were moved during the last three days of life went from 10.3 percent in 2000 to 16.5 percent in 2009.
  • More than 11 percent of the Medicare patients who died in 2009 had three or more hospitalizations during the last 90 days of life.
  • Although hospice use among the Medicare patients more than doubled, to 42.2 percent in 2009, some 28.4 percent of those patients received such services for three days or less. And about one-third of those short hospice stays were preceded by an ICU stay.

“We found, overall, the pattern of healthcare utilization for dying patients between 2000 and 2009 is best summarized by more ICU utilization, more repeat hospitalizations and more transitions in the last three days of life,” said Teno.

“The importance of our study is to reflect on how we’re taking care of dying patients in the United States,” she added. “…What are the policy changes that we need to do to ensure that a patient’s wishes are honored in the last days of life? We want to incentivize physicians to talk openly with patients about their prognosis, about what the patient’s goals of care are, and make sure they are creating a care plan that honors that dying patient’s wishes.”

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Comments (2)

End of life care still needs our attention

As a practicing internist, I believe the findings of this study are borne out in real life. On a societal level, we may be becoming more familiar with hospice as an option, but many, many times the decisions and goals are not well anticipated and thus end up being impulsive and inconsistent. Health Care providers know full well that care near the end of life is futile, but there are a number of factors that impede rational decisions, amongst them the financial incentives of our fee-for-service payment system, and families that are ill prepared for times when loved ones face potentially critical illnesses.

A recent study out of Yale found that among patients with end stage dementia, though all surrogates thought that comfort was the highest priority, many of these vulnerable patients still received invasive tests and procedures before their death. Most interesting, patients whose surrogates thought they best understood the natural history of dementia were least likely to receive those invasive interventions. The obvious conclusion is that additional efforts at Advanced Care Planning- discussions among families, patients and providers- is sorely needed.

dying cheap and well

Thanks to Susan Perry for putting a very important question out for discussion. As an oldster, my health care directive is very explicit about avoiding burdening myself, my family and the taxpayers with aggressive care. It's time we faced both life and death realistically. Breathing is not living in my book.