Hospice use rises, but help too late

End- of- life services are too often a mere add- on to ICU care

More Americans are dying in hospice, but the comfort care is too late and too short, according to a major new national study.

In the past decade, hospice use has risen, but so has time spent in hospitals’ high- cost intensive care units, the Brown University analysis found.

The paradoxical finding comes with this explanation: Patients are increasingly admitted to hospice only after aggressive ICU care has failed — and they arrive desperately ill with too little time to benefit fully from pain control and other measures, reported Dr. Joan Teno and her team.

“For many patients, hospice is an ‘ add- on’ to a very aggres--

sive pattern of care during the last days of life,” said lead author Teno, professor of health services policy and practice in the Public Health Program at Brown University.

“The findings reveal that the goals of many Americans — to avoid end- of- life heroics and die at home, in relative comfort — still remain out of reach,” she said. The study is published in Wednesday’s issue of the Journal of the American Medical Association.

The phenomenon was the subject of the Bay Area News Group’s yearlong Cost of Dying series.

Anational expert on end of-life care said the report supported concerns that hospice is too short for too many patients.

“When a hospice patient is under care for only a couple of days, it’s unlikely that the patient or the family caregivers are able to fully benefit from the many specialized services” hospice offers, said Jon Radulovic of the National Hospice and Palliative Care Organization in Alexandria, Va.

The team studied the medical records of nearly 850,000 Medicare beneficiaries who died in 2000, 2005 and 2009, comparing where they died and their medical treatments.

While the proportion of dying seniors using hospice care increased to 42.2 percent in 2009 from 21.6 percent in 2000, the proportion who were in intensive care in the last month of life also increased to 29.2 percent in 2009 from 24.3 percent in 2000.

Of those referred to hospice, 28.4 percent died within three days of care. And 40 percent of those late referrals came after a hospitalization with an intensive care stay.

“The increased availability of palliative and hospice care services does not appear to have changed the focus on aggressive, curative care,” according to an accompanying editorial by geriatricians Dr. Grace Jenq and Dr. Mary E. Tinetti of the Yale School of Medicine. “Hospice services appeared to be tagged on to the last days of life,” they wrote.

Factors driving the trend include physician attitudes, the financial incentives of fee- for- service care and too few timely conversations with patients and their family, according to Teno.

“We need to transform our health care system … to one where people are not paid for just one more ICU day,” Teno said.