What is better for the end of life, being at home with family or in the hospital with all the life saving equipment and technology available?
As I do geriatric house calls around the San Francisco Bay Area, I am asked this question all the time. Like many areas in geriatrics, the expected life span of a patient is often quite difficult to pinpoint. This is a huge reason why there’s a growing trend for patients to be bounced from hospice care.
I’ve been a hospice medical director, and I’ve worked through the formulas, the algorithms, for admitting a patient to hospice, or not doing so. As medical professionals, we do our best. But I’ve seen it again and again:
• An elder may be seem to be at death’s door. Then, inexplicably, that elder will rally and hang on to life for months more.
• Or, conversely, a patient may be declining, and then suddenly take a turn for the worse and die.
It’s so difficult to assign probabilities to individual cases. For instance, a patient with advanced dementia has a 25 percent higher risk of dying from pneumonia than another elderly patient. But what if the patient in front of me never gets pneumonia?
I understand that hospice facilities need to be reserved for the patients that most need them. That’s why each hospice case needs to be recertified every 60 to 90 days. Sometimes, a patient may be clearly be on a long downslide toward death, and yet not be expected to die within the next six months (the standard required for admission to hospice).
I think the most important thing to remember—whether the timeline is 9 months or 9 days—is that we make sure we are protecting elderly patients from procedures or treatments that will be painful and distressing, but have little chance of prolonging life.
In my practice, this means:
• I do everything I can to keep my declining patients out of the emergency room and the hospital. Patients in what probably will be their last year of life seldom win any extra days by running off to the hospital. Many, many procedures can now be done at home: blood tests, x-rays even dental care. Staying in place is more reassuring for elders, especially those that suffer from dementia.
• I always weigh whether the distress of a procedure is outweighed by the benefit. For instance, if a declining elder falls and may have a fracture, I would generally recommend that an x-ray be done. When a patient is dying, our primary goal should be the patient’s comfort. No one should have to endure the pain of a broken bone, even someone who’s dying.
So these are the questions to ask:
- Will the procedure really prolong life?
- Could the procedure be done without moving the patient from their residence?
- Will the procedure maximize comfort and peace of mind?
Of course, other physicians may have different ways to judge whether hospice, or a particular procedure, is warranted. What do you think? Are there other things we physicians should take into account?
Recently, The Washington Post ran a story investigating the increased use of hospice care. Its investigation found that the number of “hospice survivors” has increased greatly in the last few years. That is, people are put on hospice. Then they get better, and come off hospice. The Post’s story suggested that one reason this happens is that hospice firms have gotten better at recruiting patients, and that they have a motivation to recruit patients who aren’t quite dying yet. These sorts of patients need less care and stay on hospice longer. As the story’s headline put it, “Hospice firms draining billions from Medicare.” Of course, as a geriatrician doing house calls in the San Francisco Bay Area, I completely agree that it’s best when families can care for elders at the end of life. But I know from experience that this is just not possible for many families. Sometimes, adult children live far away. Other times, relatives simply do not have the resources—whether of money, of time, of expertise or of all three—to provide hospice care to their loved one.
Hospice care can be a great boon at the end of life. The popular perception is that “hospice” means “giving up.” Actually, patients on hospice—care that emphasizes alleviating symptoms rather than a cure—tend to live a bit longer than similar patients who don’t get hospice care.
While the Post’s investigation found an increase in patients enrolling in hospice too early, many patients enroll in hospice care too late, or not at all. For instance, only one-third of Medicare patients with a dementia diagnosis currently receive hospice care. And according to 2013 figures, the median number of days in hospice care was about 18.7 days.
What worries me is that our “fee-for-service” model of health care emphasizes profit incentives, there are just too many angles to squeeze. This hospice situation is just the latest.
A few years ago, it was nursing homes that were maximizing the number of Medicare dollars they could grab. Then the requirements tightened, and now almost none of my patients qualify for Medicare-paid nursing home care. I even had a patient who was refused nursing home care after a hip replacement, a situation in which a month or two of nursing home care would seem to be an obvious choice.
So now it’s hospice care that appears to be the profit center: The medical groups and hospitals have an incentive to release patients into hospice care. If a patient is put on hospice, they will not “bounce back” to the hospital for 30 days. In our current system, hospitals and medical groups make money from doing procedures, i.e. “fees for services.” They don’t make money taking care of patients in need of chronic care or recovery care, so they push those patients into hospice. And, apparently, many of these patients don’t die and “graduate” from hospice care.
I believe that the problem is not Obamacare, and it’s not Medicare. The problem is that we still seem to be too wedded to this “fee for service” model. It would make so much more sense if doctors, hospitals and medical groups were free to consider the need of the patient foremost. Everyone will tell you that that’s the case now, but the economic pressures in medicine are intense. Of course, hospitals and doctors want to care for patients but they also need to keep the lights on.
There are no great answers here, but it seems to me that a single payer medical system would avoid the kind of distortions like this spike in patients referred to hospice too early. In the meantime, I worry for the patients.
Elizabeth Landsverk, MD Specialist in Geriatrics
Board Certified in Geriatrics, Internal and Palliative Care Medicines. House calls throughout the San Francisco Bay Area