Research Show That Hospice Use Increases Patient Satisfaction

The results of this investigation demonstrate that greater use of hospice care during the last 6 months of life is associated with improved patient experience, including satisfaction and pain control, as well as clinical outcomes of care, including decreased ICU and hospital mortality. Exploring the association of hospice care on patient experience and outcomes of care

Research Validates That Hospice Saves Medicare Dollars

New research published in the March issue of Health Affairs found that hospice enrollment saves money for Medicare and improves care quality for Medicare beneficiaries with a number of different lengths of services. Hospice lowers costs, improves quality of care

Patients live longer under hospice

In this study, hospice patients (particularly those with specific cancer and congestive heart failure diagnoses) lived longer than non-hospice patients.

In a recent study, hospice patients (particularly those with specific cancer and congestive heart failure diagnoses) lived longer than non-hospice patients. The study was published in the Journal of Pain and Symptom Management in March of 2007.

Quoting from the NHPCO website:

“Among the patient populations studied, the mean survival was 29 days longer for hospice patients than for non-hospice patients. In other words, patients who chose hospice care lived an average of one month longer than similar patients who did not choose hospice care.”

“Longer lengths of survival were found in four of the six disease categories studied. The largest difference in survival between the hospice and non-hospice cohorts was observed in CHF patients where the mean survival period jumped from 321 days to 402 days. The mean survival period also was significantly longer for the hospice patients with lung cancer (39 days) and pancreatic cancer (21 days), while marginally significant for colon cancer (33 days).”

“There’s an inaccurate perception among the American public that hospice means you’ve given up,” said J. Donald Schumacher, NHPCO president and CEO. “Those of us who have worked in the field have seen firsthand how hospice can improve the quality of and indeed prolong the lives of people receiving care. Benefits of hospice have been reinforced by positive stories like that of Art Buchwald who seemed to thrive under the care of hospice.”

“Researchers cited several factors that may have contributed to longer life among patients who chose hospice. First, patients who are already in a weakened condition avoid the risks of over-treatment when they make the decision to receive hospice care. Second, hospice care may improve the monitoring and treatment patients receive. Additionally, hospice provides in-home care from an interdisciplinary team focused on the emotional needs, spiritual well-being, and physical health of the patient. Support and training for family caregivers is provided as well. This may increase the patient’s desire to continue living and may make them feel less of a burden to family members.”

Widows/widowers benefit if their spouse received hospice services

Research indicates that hospice reduces the risk of death in widows and widowers after the death of their spouse.

Research by Nicholas A. Christakis, Harvard Medical School, and Theodore J. Iwashyna, University of Pennsylvania, published in Social Science and Medicine, indicates that hospice reduces the risk of death in widows and widowers after the death of their spouse.

Quoting from the research paper: 

Using a population-based sample of the elderly, we assessed the potentially beneficial impact of hospice—a supportive type of medical care that might be offered to dying patients— on the spouses of patients who died. We found that this type of care, even when used for a median of 3-4 weeks, may be associated with the subsequent health outcomes of bereaved spouses in that it reduces their risk of death.This impact is present in both men and women, but it is statistically significant, and possibly larger, in bereaved wives…. Indeed, the end-of-life care a woman’s husband receives has an impact on the woman similar in magnitude to that of various other modifiable diet and exercise risk factors. 

In short, mortality in a spouse is clearly a stressful life event, one which itself also deprives the individual of one of their principal sources of social support. As a result of these two parallel effects, the individual should be at increased risk for subsequent mortality himself. In this light, our findings suggest that hospice care might both decrease the stressfulness of the death of the decedents and simultaneously provide some social support that potentially partially replaces the support lost due to the death of the spouse; these twin effects might be the mechanism involved in the mitigation by hospice of the short-term rise in mortality ordinarily associated with bereavement. 

…since the manner of caring for patients might have effects beyond the individual patient, our findings suggest an important clinical consideration for doctors caring for terminally ill patients or their partners.Physicians concerned about the impact of impending bereavement have another tool at their disposal beyond bereavement counseling or medication; namely, they can attend to the specific manner of death of the sick partner before it occurs. To do so may also carry out the physician’s primary duty to respect patients’ wishes because terminally ill patients consider it very important that they not burden their family members. Our results suggest that hospice care may offer a tool to patients and physicians that may soften the blow of the decedent’s death. 

How we care for the terminally ill may have lasting health effects for their loved ones. 

Hospice helps people with dementia

“Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.”

Does Hospice Improve Quality of Care for Persons Dying from Dementia?

From the Journal of the American Geriatrics Society Download the Article 
Volume 59, Issue 8, pages 1531-1536, August 2011
Joan M. Teno MD, MS1, Pedro L. Gozalo PhD1, Ian C. Lee1, Sylvia Kuo PhD1, Carol Spence PhD2, Stephen R. Connor PhD3, David J. Casarett MD, MA4 

“People whose loved ones received hospice care reported an improved quality of care, and had a perception that the quality of dying was improved as well,” said Dr. Joan Teno. “This is one of just a few studies out there that has examined dying with dementia where the predominant site of care is a nursing home and can report the benefits of hospice services. As just one example, for nursing home patients not in hospice, one in five family members reported an unmet need for shortness of breath while that was only 6.1 percent for people in hospice.”

The researchers’ conclusion:

Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.

Hospice care in nursing home provides benefits

Hospice care in nursing homes provides many benefits, according to researchers with the Department of Health Policy at the Harvard Medical School.

Hospice care in nursing homes provides many benefits, according to researchers with the Department of Health Policy at the Harvard Medical School. 

Quoting the NHPCO Press release:

Hospice Care in the Nursing Home Offers Benefits to Residents at End of Life 

Article Finds Great Promise for Increasing Availability of Hospice in Nursing Homes 

(Alexandria, Va) – Researchers at the Harvard Medical School, Department of Health Policy have published a review article of hospice care in the nursing home and found a number of benefits indicating that greater availability of hospice holds promise in the nursing home setting. 

Key findings reported in an article published in the September 2009 issue of the Journal of Pain and Symptom Management found: 

  • Hospice in nursing homes can provide high quality end-of-life care and offers benefits such as reduced hospitalizations and improved pain management.
  • The provision of hospice care in nursing homes has been shown to have positive effects on non-hospice residents, suggesting indirect benefits on nursing home clinical practices.
  • Hospice is relatively underutilized among nursing home residents at the end of life.

While most hospice care in the U.S. is provided in the home, the use of hospice in nursing homes has risen in recent years; growth that has coincided with increased utilization of hospice care more generally. 

The National Hospice and Palliative Care Organization reports that more than 1.4 million Americans receive care from the nation’s hospice providers annually with 22.8 percent residing in a nursing home. Yet, only six percent of nursing home residents in the U.S. currently elect the hospice benefit, even though nearly one-in-four deaths in the U.S. occur in a nursing home. 

“More and more hospices are successfully caring for people residing in nursing homes. This growth reflects the increased provision of quality care for dying persons who are not in the traditional ‘home’ setting. For many people, the nursing home is their home and they deserve the compassionate, quality care that hospice and palliative care providers are trained to deliver,” said J. Donald Schumacher, NHPCO president and CEO. “This literature review points out many positive benefits of hospice in the nursing home and it reminds us all of the importance of caring for this population.” 

Authors of the study found that nursing home hospice patients received the same high-quality care as those hospice patients living in their own homes. 

Compared to similar residents not enrolled in hospice, previous studies reviewed by the researchers found nursing home hospice patients were more likely to be assessed for pain, twice as likely to receive daily treatment for pain, and more likely to receive pain management in accordance with clinical guidelines. They were also less likely to require hospitalization in the final 30 days of life. 

The importance of communication and coordination between the hospice provider and the nursing home staff as well as the need for more education on end-of-life care among professionals was another point clearly shown in the literature reviewed. 

“Hospice providers recognize the need for ongoing outreach and awareness building, both among nursing home professionals as well as members of the public who may need end-of-life care,” Schumacher remarked. “For example, the misconception that hospice might hasten a patient’s death is something we in our field must continually clarify. In fact, some studies have shown that hospice patients live, on average, longer than similar patients who do not opt for hospice care.” 

The article was written by David G. Stevenson, PhD, and Jeffrey S. Bramson, BA, of the Harvard Medical School, Department of Health Policy. Support for this research was provided by NHPCO.

Caregivers at risk when loved ones die in hospitals

“Bereaved caregivers of terminally ill cancer patients who died in hospitals or intensive care units (ICUs) are at increased risk for developing psychiatric problems… according to a study published in the Journal of Clinical Oncology.”

Read the study 
Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health

Quoting the National Cancer Institute’s NCI Cancer Bulletin from September 21, 2010:

Hospitalization Near Death May Diminish Mental Health of Caregivers and Quality of Life for Cancer Patients

Bereaved caregivers of terminally ill cancer patients who died in hospitals or intensive care units (ICUs) are at increased risk for developing psychiatric problems compared with caregivers of patients who died at home, according to a study published online September 13 in the Journal of Clinical Oncology.

The prospective study of 333 dying cancer patients and their closest caregivers-led by Dr. Alexi A. Wright and colleagues at Dana-Farber Cancer Institute, Harvard Medical School, and Brigham and Women’s Hospital-was designed to determine principally whether the place of death for patients with cancer was associated with the patients’ quality of life at the end of life, and also whether it was linked with increased risk for bereavement-related psychiatric disorders in their caregivers. 

The researchers reported that caregivers of patients who died in ICUs had an increased risk of developing post-traumatic stress disorder (PTSD) compared with caregivers of patients who died at home with hospice care: 21.1 percent compared with 4.4 percent. “To our knowledge, this is the first study to show that caregivers of patients who die in ICUs are at a heightened risk for developing PTSD,” they wrote. In addition, caregivers of patients who died in the hospital had higher odds of suffering prolonged grief disorder: 21.6 percent compared with 5.2 percent among caregivers of patients who died with home hospice.

Families less happy when their family member referred late

Families who perceived that their loved ones were referred to hospice “too late” were less happy with the end-of-life care of their family member.

Families who perceived that their loved ones were referred to hospice “too late” were less happy with the end-of-life care of their family member. In a study published in the July issue of the Journal of Pain and Symptom Management, one out of ten families felt that hospice care was not provided soon enough. 

Quoting from the NHCPO website: 

“Timely referrals ensure that patients and families can experience the wide range of available services and benefits hospices can provide. Hospice provides symptom control, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. Family members also receive support, caregiver training, and help coping with the loss of their loved one.” 

“Experts agree that hospice is most beneficial when provided for at least three months. NHPCO reports that the median length of service was 26 days in 2005 with 30 percent of people served by hospice in the U.S. dying in seven days or less. Furthermore, while eight out of 10 Americans have indicated they would prefer to spend their final days at home, those who received hospice for seven days or less were more likely to be cared for outside of their homes.” 

“In many cases, families aren’t aware of what they are missing and don’t realize how hospice can make a world of difference for the comfort and quality of life for their loved ones,” [said Stephen Connor, NHPCO vice president for research]. “One of the most common complaints hospice providers hear from families following the death of a loved one is ‘why didn’t we get hospice care sooner.'” 

Care varies for elderly patients with cancer

How elderly patients with poor prognosis cancer are cared for varies depending on where they live and receive care. “The report demonstrates that many hospitals and physicians aggressively treat patients with curative attempts they may not want, at the expense of improving the quality of their last weeks and months.” Dartmouth Atlas Report on Cancer Care

The Dartmouth Atlas of Healthcare website
Download the study

From the report:

“This Dartmouth Atlas report examines how elderly patients with poor prognosis cancer are cared for across regions and hospitals and finds remarkable variation depending on where the patients live and receive care. Even among the nation’s leading medical centers, there is no consistent pattern of care or evidence that treatment patterns follow patient preferences. Rather, the report demonstrates that many hospitals and physicians aggressively treat patients with curative attempts they may not want, at the expense of improving the quality of their last weeks and months.”

Patients with cancer … want honest conversations with their providers. This includes balanced information about the chances of disease remission or progression, and the possible benefits and discomforts of different treatment options. Most importantly, they want to be active partners with clinicians in making the decisions about the type and place of care. Too often, care for patients near the end of life falls short of the desires of patients and families.”

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Fundamental to patient-centered cancer care are health care providers educating patients about their prognoses, eliciting their preferred treatment approaches, and formulating care plans that respect their choices regarding the goals of care. The majority of cancer patients want to be involved in their medical care, but a collusion of silence and health care fragmentation results in far too many patients uninformed of their prognoses and the option of hospice. Many are informed far too late, resulting in hospice referral in the last three days of life.This pattern of care often leaves the dying patient in pain and without the opportunity to say “goodbye, I love you, please carry on.”

Joan M. Teno, MD, MS

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As a doctor caring for people who have serious, life-threatening conditions, I commonly ask patients to consider a few basic questions: What is most important to you as you think about the end of your life? Where would you like to be during your final days? Who would you want to care for you? What types of treatment would you want, or not want?

It is important for each of us to discuss our personal answers to these questions with our families and our doctors. It is also important for each of us to complete an advance directive that formally names those we trust to speak for us in making health care decisions if we become unable to speak for ourselves.

For people who want to be at home through the end of life, and for families who want to care for them, hospice is essential. Hospice programs provide medications needed to control pain and other discomfort, visits by highly skilled nurses, a team of professionals, and quick access to someone to answer questions or manage problems 24 hours a day.
Ira Byock, MD

  • Quoting the NHPCO press release:

    “The Dartmouth Atlas Project is to be commended for undertaking this thorough examination of end-of-life care for Medicare beneficiaries with advance cancer,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization. “While the findings of variation in care are not necessarily a surprise, one of the key messages that I take away from this report is the critical need for hospitals and all healthcare professionals to ensure that all patients are informed earlier about the course of an illness and the range of options available – options that include hospice and palliative care.”