Fewer die in hospitals as hospice, intensive care use increase
More people are dying in hospice care rather than in the hospital, though the shift hasn’t led to less aggressive treatment or lower costs as patients spend additional time in intensive care units in the last month of life.
Hospice care among the elderly doubled to about 40 percent in the past decade, according to a study in the Journal of the American Medical Association. For many, the transition to hospice came only in the final few days of life, often after time in the intensive care unit and multiple hospitalizations.
Hospice care programs treat pain and discomfort of dying patients whose underlying disease can’t be cured. The programs often enable patients to die at home and are far less costly than hospital care. Joan Teno, a doctor who focuses on end-of-life care and one of the study’s authors, said she is troubled that terminally ill patients aren’t admitted sooner to hospice, where they can benefit from supportive care, instead of first going through lengthy intensive care unit and hospital stays.
“Hospice is now just an add-on to an aggressive pattern of care where they go from hospitalization, to the ICU to hospice in the last days of life,” said Teno, a professor of health services, policy and practice at Brown University in Providence, R.I. “This isn’t going to change our health-care spending or improve quality of care at the end of life.”
In 2009, 42 percent of elderly patients died in hospice care, either in their home or in a facility, an increase from 22 percent in 2000, the study found. About 59 percent of cancer patients and 48 percent of dementia patients were enrolled in hospice at the time of death, the researchers said.
Meanwhile, deaths in the hospital dropped to 25 percent in 2009 from 33 percent in 2000, the study found.
Still, thousands of those patients weren’t put into hospice care until the final days or hours of their life, which may have put added stress on patients and families and given them little chance to benefit, said Mary Tinetti, a professor of medicine at Yale University in New Haven, Conn., who wrote an editorial accompanying the article. About 14 percent of patients moved into hospice during the last three days of life, compared with 10 percent in 2000, the study said. Among those, 40 percent previously had been in a hospital.
“The idea was that people would be getting into hospice for long enough to really benefit from the focus on comfort and spirituality and getting ready for the end of life,” said Tinetti, who focuses on elderly patients and end-of-life care. “Although more people are going to hospice, which is a good thing, it is pegged on the last few days of life, probably not long enough to benefit.”
In some cases, doctors may not be taking the extra time to talk to patients about hospice and end of life care, Teno said.
“We have created a system where all the financial rewards are more care, more ICU,” Teno said. “We pay for an ICU day, we don’t pay doctors to talk to dying patients about hospice and doctors to talk about goals of care.”
Patients were also receiving more aggressive care at the end of life, with the proportion sent to the intensive care unit a month before their death rising to 29 percent in 2009 from 24 percent in 2000.
The study looked at medical records for more than 800,000 people enrolled in Medicare who died between 2000 and 2009.