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Hospice Too Often Used as ‘Last Resort’ for Many Seniors

Three days.

That's the maximum amount of time that 28 percent of seniors in hospice spend getting specialized care, according to a recent report in the Journal of the American Medical Association.

Researchers from Brown University examined the records of 848,000 Medicare fee-for-service beneficiaries to uncover trends in end-of-life care for seniors between the years of 2000 and 2009.

They unearthed a mixture of positive and negative developments.

The good news: overall, the number of seniors who are dying in hospice care settings is steadily increasing, from about 22 percent in 2000 to just over 42 percent by 2009.

However, dying seniors are also experiencing, "More ICU utilization, more repeat hospitalization and more late transitions in the last few days of life," according to lead study author Joan Teno, M.D., M.S., professor of health services, policy and practice at the Warren Alpert School of Medicine.

End-of-life moves take toll on health, finances

Teno's team discovered a 48 percent increase in the number of care transitions (i.e. going from home, to hospital, to nursing home, to hospice care, etc.) faced by fragile elders in their final weeks.

These moves have the potential to deal a series of substantial blows to a senior's health and finances.

From the medical standpoint, more changes means there's more room for error. There's a greater likelihood that some important element of a senior's care will get lost in the shuffle.

"If you go to three different health care settings, you essentially have three different health care providers who have three different ways of doing things, from dispensing meds to helping with activities of daily life," Judy Bartel, Chief Clinical Officer for Hospice of the Western Reserve, points out.

Disruptions in routine and environmental changes can also have a profoundly negative impact on the physical, emotional and cognitive health of a frail senior.

Bartel adds that the financial costs of multiple care transitions at the end of an elder's life can add up to astronomical amounts, particularly if they don't have enough insurance coverage.

She recounts the story of her own mother, whose week long stint in the hospital prior to going on hospice ended up costing her and her family $15,000 (the 20 percent co-pay not covered by Medicare) because she lacked supplemental insurance.

The doctor's dilemma

According to Bartel, part of the reason more people don't get hospice care sooner is that we live in a "death-defying society."

We assume (and hope) that advances in modern medicine can somehow cure all of our ailments. For many chronic illnesses, however, the best that medicine can do is temporarily ward off the inevitable.

"Many people don't recognize that a disease is terminal and progressive," says Bartel. "I can't tell you how many times I hear, ‘My mother has a little bit of heart failure,' or that a senior with COPD (chronic obstructive pulmonary disorder) has a ‘little bit of a breathing problem.'"

This issue is caused, in part, by miscommunication between doctor, patient and caregiver.

Medicare requires hospice patients to have a doctor-approved prognosis of six months or less—something that can difficult for doctors to determine, depending on the disease.

Then there's the issue of how the physician interprets the medical maxim; "First, do no harm."

"Many healthcare professionals don't consider hospice as a treatment option sooner because they perceive end-of-life care as giving up, or ‘doing harm,' by not continuing to treat a disease progressively," says Nicole Levitan, a social worker at MJHS Menorah Center for Rehabilitation and Nursing Care in Brooklyn, NY.

Dementia difficulties

The number of individuals with dementia who spend their final days in a nursing home, or an ICU has been steadily increasing over the past ten years, according to Teno's team.

Dementia presents a particular challenge for people seeking hospice care.

The unpredictable nature of the cognitive decline in someone with dementia makes it hard for a doctor to provide an accurate estimation of how long a person with the disease will live.

Typically, a dementia sufferer has less than a week left of life when they go on hospice.

Levitan considers these wasted opportunities because hospice offers a number of unique benefits to people with dementia, including music therapy and one-on-one social interactions, both of which can be particularly comforting to a person struggling with profound memory loss.

Different hospices, different rules

An additional barrier to hospice care for some seniors was highlighted in a recent report of a nationwide survey of 600 hospices, published in the journal, Health Affairs.

The results of the investigation showed that 78 percent of hospices had enrollment guidelines that could be overly-restrictive, particularly for seniors with pricey health needs.

To get Medicare to cover hospice costs, a senior must forfeit their right to receive curative treatment for their condition. They are only allowed to get palliative treatments aimed at minimizing their physical, emotional and spiritual discomfort.

The issue, as pointed out by the study authors, is that some treatments can fall into both the curative and pain relief care camps.

For instance, most hospice providers won't accept cancer patients who want to continue undergoing chemotherapy because it is considered a curative treatment. However, chemotherapy could also be considered a palliative treatment if it is used to shrink a tumor that is causing a person pain.

Since their care practices are heavily monitored by Medicare, hospice providers must tread lightly to avoid having their funding cut. Thus, they adopt more strict enrollment policies for applicants.

According to the study authors, smaller hospice centers and for-profit hospices tended to have more restrictive enrollment guidelines.

It takes time to choose the right hospice care provider, time that a dying senior may not have. 

Bartel urges seniors and their caregivers to proactively research hospice care options in their area. "Call too soon, call often, let us say no to you, rather than you saying no to the concept of hospice," she says.

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