Quo Vadis ICU Hospitalization for End-of-Life Care?

Fri, 11/7/08 - 10:23am
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Author(s):

Albert J. Finestone, MD, MSc, FACP, and Gail Inderwies, RN, BSN, MBA, CHPN

Author Affiliations:

Dr. Finestone is Director, Institute on Aging, Adjunct Professor of Medicine, Associate Dean, CME, Emeritus at Temple University School of Medicine, and Consortium Project Director, Geriatric Education Center/PA; Ms. Inderwies is Medical Director of Keystone Hospice, Wyndmoor, PA.

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We all recognize the 100% mortality in this world. Care for the dying is a complex enterprise that must involve multiple professionals and nonprofessionals. The physical, emotional, and social needs of the dying person are addressed by acknowledging the fear, anxiety, loneliness, and isolation that is experienced during an end-stage illness.

The association of hospice with death is a major impediment to hospice enrollments, as fear of death is a pervasive human emotion. Palliative care and hospice patients are often not capable of engaging in the types of interactions required to make end-of-life choices independently, and the influence of others is crucial both physically and psychologically. The role of family in the choice of, and evaluation of, hospice care has long been recognized.1

However, next to the influence of friends and relatives, healthcare professionals are logically the most influential group during end-of-life decisions. It has been suggested that quality of end-of-life care results when, among other things, healthcare professionals promote shared decision-making.2 Advising hospice by a physician in many instances is an admission of failure. In addition, at times, morbidity and mortality conferences evolve into “Why did the patient die?” Many years ago during my fellowship in Pathology, I (AJF) would carefully look for a patch of pneumonia for a cause of death. The concept of multiple-organ failure was not in current use then. It is still difficult for many physicians to say that death is coming and that hospice is a good choice.

The hospice concept was pioneered in 1967 by English physician, nurse, and social worker Dr. Dame Cicely Saunders. In the United States, the hospice movement emerged in the mid-1970s. In 1982, Congress initiated the hospice benefit under the Tax Equity and Fiscal Responsibility Act (TEFRA), a landmark public policy decision to include hospice care in the Medicare program. Hospice core services include professional nursing care, personal assistance with activities of daily living, various forms of rehabilitation therapy, dietary counseling, psychosocial and spiritual counseling for both patient and family, volunteer services, respite care, provision of medical drugs and devices necessary for palliative care, and family bereavement services following the patient’s death. Hospice care is provided by an interdisciplinary care team comprised of nurses, social workers, pastoral counselors, nursing assistants, and other healthcare professionals under the management of the patient’s own primary care physician or one affiliated directly with hospice program.

There is ample evidence to support a higher quality of life in hospice patients as compared with terminally ill patients in the hospital setting. Numerous studies evaluating quality of end-of-life in settings other than the hospital show that family members are consistently more likely to report a favorable dying experience of the decedent when hospice or palliative care is chosen as compared with hospitalization.3-6 There is growing evidence that hospice provides high-quality care with high consumer satisfaction.7 Research has suggested that for certain diagnoses such as congestive heart failure, when compared with patients who do not choose hospice care, hospice patients live longer for an average of 29 days,8 and hospice care may be associated with a modest cost savings.9

Most elderly patients are eligible for Medicare Hospice Benefits.

References:

1. Connor SR, Teno J, Spence C, Smith N. Family evaluation of hospice care: Results from voluntary submission of data via website. J Pain Symptom Manage 2005;30:9-17.
2. Teno JM, Casey VA, Welsh LC. Patient-focused, family-centered end-of-life medical care: Views of the guidelines and bereaved family members. J Pain Symptom Manage 2001;22:738-751.
3. Dawson NJ. Need satisfaction in terminal care settings. Soc Sci Med 1991;32:83-87.
4. Hanson LC, Danis M, Garrett J. What is wrong with end-of-life care? Opinions of bereaved family members. J Am Geriatr Soc 1997;45:1339-1344.
5. Nolen-Hoeksema S, Larson J, Bishop M. Predictors of family members' satisfaction with hospice. Hosp J 2000;15:29-48.
6. Teno JM, Clarridge JB, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA 2004;291:88-93.
7. Casarett D, Quill T. “I’m not ready for hospice”: Strategies for timely and effective hospice discussions. Ann Intern Med 2007;146(6):443-449.
8. Connor SR, Pyenson B, Fitch K, et al. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage 2007;33:238-246.
9. Pyenson B, Connor S, Fitch K, Kinzbrunner B. Medicare cost in matched hospice and non-hospice cohorts. J Pain Symptom Manage 2004;28:200-210.
10. Foley KM, Gelbard HE, eds. Improving Palliative Care for Cancer. Washington, DC: National Academy Press; 2001.
11. Hanson LC. Palliative care: Innovation in care at the end of life. N C Med J 2004;65:202-208.
12. Russell K, LeGrand S. “I’m not that sick!” Overcoming the barriers to hospice discussions. CleveClin J Med 2006;73:517, 520-522, 524.
13. Connor SR, Tecca M, LundPerson J, Teno J. Measuring hospice care: The National Hospice and Palliative Care Organization National Hospice Data Set. J Pain Symptom Manage 2004;28:316-328.
14. Enguidanos S, Yip J, Wilber K. Ethnic variation in site of death of older adults dually eligible for Medicaid and Medicare. J Am Geriatr Soc 2005;53:1411-1416.
15. Colon M, Lyke J. Comparison of hospice use and demographics among European Americans, African Americans, and Latinos. Am J Hospice Palliative Care 2003;20:182-190.
16. Johnson KS, Kuchibhatala M, Sloane RJ, et al. Ethnic differences in the place of death of elderly hospice enrollees. J Am Geriatr Soc 2005;53:2209-2215.
17. Kapo J, Macmoran H, Casarett D. “Lost to follow-up”: Ethnic disparities in continuity of hospice care at the end of life. J Palliat Med 2005;8:603-608.
18. Burrs FA. The African American experience: Breaking the barriers to hospices. Hosp J 1995;10:15-18.
19. Gordon AK. Hospice and minorities: A national study of organizational access and practice. Hosp J 1996;11:49-70.
20. Reese DJ, Ahern RE, Nair S, et al. Hospice access and use by African Americans: Addressing cultural and institutional barriers through participatory action research. Soc Work 1999;44: 549-559.
21. Born W, Greiner KA, Sylvia E, et al. Knowledge, attitudes, and beliefs about end?of-life care among inner city African Americans and Latinos. J Palliat Med 2004;7:247-256.
22. Torke AM, Garas NS, Sexson W, Branch WT. Medical care at the end of life: Views of African American patients in an urban hospital. J Palliat Med 2005;8:593-602.
23. Duffy SA, Jackson FC, Schim SM, et al. Racial/ethnic preferences, sex preferences, and perceived discrimination related to end-of-life care. J Am Geriatr Soc 2006;54:150?157.
24. Winzelberg GS, Hanson L, Tulsky JA. Beyond autonomy: Diversifying end-of?life decision-making approaches to serve patients and families. J Am Geriatr Soc 2005;53:1046-1050.
25. Rhodes RL, Teno JM, Welsh LC. Access to hospice for African Americans: Are they informed about the option of hospice? J Palliat Med 2006;9:268-272.
26. Hartocollis A, Fessenden F. In New York City, two versions of end-of-life care. The New York Times. May 30, 2008.