Hospice care used more, but often too late

Janice Lloyd, USA TODAY | USATODAY

Twice as many elderly people died in hospice care as in a hospital or nursing home compared with a decade ago, but hospice is often treated as a last resort — and used too late to benefit patients and their families, says a study released Tuesday.

The researchers examined Medicare records for 840,000 people 66 or older who died in 2000, 2005 and 2009. They found intensive-care use, hospitalization and the rate of health care transitions increased in the last month of life before patients entered hospice. Length of stays in intensive care also increased.

Hospice care aims to address the physical, emotional, social and spiritual needs of dying patients and their families and to control pain, says the study's lead author, Joan Teno, professor of health services policy and practice at Warren Alpert School of Medicine at Brown University in Providence.

But this study shows that "for many patients, hospice is an add-on to a very aggressive pattern of care during the last days of life,'' she says. "We suspect their needs and their families didn't get the support they needed."

More than a quarter of hospice use in 2009 was for three days or less, and 40% of those late referrals followed a hospitalization with an intensive-care stay.

"I think every person needs to make a decision based on what is important for them in the last months of life,'' says Teno, a palliative care physician at Home and Hospice Care of Rhode Island. "All too often, I see doctors take aggressive approaches with treatment and only talk to patients about hospice when there is futility."

The study, published in TheJournal of the American Medical Association, appears with an editorial calling for an end to the aggressive intensive care and hospitalization at the end of life by improving communication between patients and physicians to determine what patients' want and by considering "a threshold of likely benefit and life expectancy for an ICU admission."

"If programs aimed at reducing unnecessary care are to be successful, patients' goals of care must be elicited and treatment options such as palliative and hospice care offered earlier in the process," write physicians Grace Jeng of the Yale School of Medicine in New Haven, Conn., and Mary Tinetti of the Yale School of Public Health.

"This country has invested heavily in building up ICU centers over the past 20 years; that pathway brings in the most money for doctors and hospitals," says study co-author David Goodman, director of the Center for Health Policy Research at Dartmouth's Geisel School of Medicine in Hanover, N.H.

But, he adds, "that's not what patients really want. This needs to be about patient autonomy. By investing more in hospice and palliative care, we can truly meet the final wishes of our patients."

Going to intensive care or moving a patient into a nursing home in their last days is spiritually disruptive to a person trying to find closure, Teno says, and also disrupts sleep and alters medicine schedules and diet.

Other highlights of the study:

-The percentage of dying seniors using hospice was 42.2% in 2009, up from 21.6% in 2000.

-People dying of cancer were more likely than those with dementia or chronic obstructive pulmonary disease (COPD) to use hospice.

-Nearly 40% of people with COPD had an ICU stay prior to death.

-The percentage of people with dementia who spent time in intensive care during the last month of life increased slightly, from 18.6% in 2000 to 21.8% in 2009. People with dementia were primarily in a nursing home, with transition to hospice in the last week of life.