At Life's End, Aggressive Care Still the Norm

While fewer older Americans are dying in hospitals, new research suggests that doesn’t mean they’re getting less aggressive care in their final days.

Even as deaths in acute hospitals declined between 2000 and 2009, the use of intensive care units in the final 30 days of life increased, as did short-term hospice use, according to a study of Medicare beneficiaries published Tuesday in the Journal of the American Medical Association. The rate of changes to care for these patients, such as transitions within the last three days of life, also increased.

Dr. Joan Teno at Brown University's medical school led the study. She says the increased use of hospice is encouraging, but worries about when seniors are referred to hospice.

“While there is greater access to hospice services, there’s also more ICU, more repeat hospitalizations, and more late transitions in the last three days of life,” Teno said during an interview. “The good news is that we are referring to hospice. The bad news is we’re referring to hospice in the last hours of life.”

Teno and her team analyzed findings of Medicare claims data from more than 800,000 seniors 66 years and older, who died in 2000, 2005, and 2009. While a 2010 report by the federal Centers for Disease Control and Prevention has looked at the patient’s location at death, researchers in this study examined beneficiaries’ medical claims for the last 180 days of life.

Hospice use at the time of death increased from nearly 22 percent in 2000 to 42 percent in 2009, the authors reported, but short stays of three days or less went from 22 to 28 percent. And 40 percent of those short stays came after time in a hospital ICU.

According to Teno, the study’s findings, particularly the increase in the number of short hospice stays following hospitalizations, suggest that aggressive care at the end of life is growing. “We really need to improve our referral patterns to make sure that people are receiving the appropriate and timely access to palliative care services at the end of the life,” she said.

Jon Radulovic, the vice president of communications of the nonprofit National Hospice and Palliative Care Organization, says the study adds to concerns about end-of-life care. “With the number of patients (in hospice) who die under seven days or less, it’s questionable whether the patient and family caregivers are able to fully benefit from the unique services that hospice offers,” he said.

With some provisions of the federal health law set to take effect in 2014, Teno sees an opportunity to hold institutions more accountable.

“The opportunity under health care reform is to really pay for quality and not pay for another day in the ICU,” she said. “Our fee-for-service system has probably resulted in overutilization of care and really, what we want to do is get the right care at the right time, for the right person, at the right location. And we want to respect the patient’s right to choose.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.