The Free Press, Mankato, MN

February 9, 2013

Our View: Hospice not being used to full advantage

The Free Press

— In the past 10 years, hospice has become a fixture in the health care system providing comfort and support to dying patients. However, a study published in the Journal of the American Medical Association is finding hospice -- and the emerging use of palliative care -- is still only an afterthought, depriving these patients the "full measure of comfort and psychological support" afforded by hospice and palliative care.

The study looked at Medicare fee-for-service records of more than 840,000 people aged 66 or older who died in 2000, 2005, or 2009 including what services were provided during the last 90 days of life and how long they received them.

Among all patients in the study, the percentage referred to hospice from ICU for just three days or less doubled over the decade to 9.8 percent from 4.6 percent. This suggests that dying patients were getting symptom control late thereby lessening the time available for psychosocial supports available with a longer hospice care.

The study's author, Dr. Joan Teno, a professor of health services policy and practice at Brown University, suggests the cause for such short relief time is tied to continued aggressive treatment partly because of physician attitudes and partly to fee-for-service reimbursements.

The conclusions in the study suggest these incentives delay the communication necessary with family members and patients to develop an end-of-life care plan designed around the patient's preferences rather than the continued heroic efforts to continue treatment right to the end.

An accompanying editorial in JAMA noted that the "increased availability of palliative and hospice care services does not appear to have changed the focus on aggressive, curative care. Hospice services appeared to be tagged on to the last days of life.

Teno said, "We need to transform our health care system ... to one where people are not paid for just one more ICU day."

But there are other factors contributing to this slow transition. The study suggests the lack of full communication leading to the unwanted care is "epidemic in many health systems." This does not rest just with health-care providers.

Families and patients need to be fully briefed on potential outcomes earlier in the treatment to determine how far curative care should go and at what point psychosocial should transition in. It is a team effort with physicians, palliative care specialists and especially families who need to accept the patients' desires and wishes and incorporate that into their emotional thinking.

Our culture trends toward more aggressive care, to do everything possible to save the patient or have them live a few more days longer without thinking about the comfort and preparation the patient may want or need.

Families should have that discussion early before trauma blinds the decision making process and overrides the true wishes of a loved one.