In a study published in JAMA, The Journal of American Medical Association, the study authors concluded that for-profit hospice agencies had a higher percentage of patients with diagnoses associated with lower-skilled needs and longer lengths of stay, when compared with nonprofit hospice agencies.  This has led other writers in publications such as the Los Angeles Times and Modern Healthcare to suggest that the for-profit hospices may be selecting patients who are less expensive to treat — leaving patients who are more costly to care for to nonprofit agencies.

The results of the study suggest that Medicare’s per diem payment structure may create financial incentives to select patients who require less resource-intensive care and have longer hospice stays.  We have been concerned for some time that Medicare’s policies have effects like this.  There can be a similar risk of “cherry picking” of patients by physicians and medical groups for the same reason.  Medicare’s “OASIS” rating system that publishes outcomes for healthcare providers may similarly encourage providers to shun patients who are so sick that they may produce bad OASIS scores for the providers.

The JAMA extract for the study can be found at this location:
Association of Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay

According to a new study published in the Journal of Clinical Oncology, the Quality of Life (“QoL”) of terminally ill cancer patients and their caregivers is significantly improved when they are cared for and eventually pass away at home with hospice care than in other settings.  According to the study’s conclusion:

Patients with cancer who die in a hospital or ICU have worse QoL compared with those who die at home, and their bereaved caregivers are at increased risk for developing psychiatric illness. Interventions aimed at decreasing terminal hospitalizations or increasing hospice utilization may enhance patients’ QoL at the EOL and minimize bereavement-related distress.

Companion care at home with personal attendants and hospice care can significantly lessen the caregiving “work” for patients’ family and friends so that they can enjoy the time that they still have together.

Professional geriatric care managers can suggest which hospices to consider for the best “fit” with the patient and family and their needs.  Not all hospices are alike, and sadly, sometimes physicians’ recommendations are based more on the physicians’ convenience than the patients’ quality of life.  Ultimately, it is the right of the patient and family to choose the hospice that they will use.

To see the abstract (the summary) of the study, see Place of Death: Correlations With Quality of Life of Patients With Cancer and Predictors of Bereaved Caregivers’ Mental Health.  You can view a pdf file of the entire published study paper at this location.

The highly-regarded New England Journal of Medicine recently published a very interesting study that concluded that terminally ill patients with metastatic non–small-cell lung cancer who received palliative care soon after diagnosis lived longer than those who did not, even when receiving less aggressive treatment at the end of their lives.

According to Wikipedia:

Palliative care (from Latin palliare, to cloak) is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. Non-hospice palliative care is not dependent on prognosis and is offered in conjunction with curative and all other appropriate forms of medical treatment.

In the United States, a distinction is made between general palliative care and hospice care, which delivers palliative care to those at the end of life; the two aspects of care share a similar philosophy but differ in their payment systems and location of services. Elsewhere, for example in the United Kingdom, this distinction is not operative: in addition to specialized hospices, non-hospice-based palliative care teams provide care to those with life-limiting illness at any stage of disease.

In plain English, this makes the case for hospice care being a very reasonable, and in fact beneficial, choice as soon as the patient becomes appropriate for hospice care, and also for pre-hospice palliative care before cessation of treatment that seeks to cure or halt the illness.

The NEJM study conclusions are very direct and clear:

Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)

For the complete study, see Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer

As humans, we have a unique ability to both accept our mortality and deny it. For those who care for the elderly, this presents a challenge. How do you ensure that your loved one’s wishes regarding hospice care and other important matters are carried out, when it’s so difficult to begin the conversation?

The last thing you want is for a sudden illness to rob your elderly relative of the opportunity to make his or her own decisions, and the only way to avoid that is to begin discussing options early, preferably while your loved one is still healthy and active. A good way to approach the subject is by examining the difficulties other family members or friends are having. For example, if an older sibling of your relative failed to designate a durable power of attorney before becoming incapacitated, you might talk about the challenges faced by his or her caregivers, and how planning ahead would have been easier for everyone involved.

Keep in mind, though, that decisions about end of life and hospice care can’t be made during a one-time conversation. The discussion will most likely be ongoing, and will cover many more topics than we’ve outlined here. A professional geriatric care manager can help facilitate conversations like this and will know what you need to talk about and how to prepare for the future.  The most important thing is to begin talking about the issues now, before there is an emergency. As hard as it is today, imagine how much more difficult it will be after your loved one becomes ill.

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