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End-of-life care often still hectic, aggressive

By Genevra Pittman

NEW YORK (Reuters Health) - Fewer elderly Americans are dying in acute care hospitals than were a decade ago, according to a new study of where Medicare beneficiaries spend their final months of life.

However, between 2000 and 2009 there was also an increase in the proportion of people admitted to the intensive care unit in the month before they died - suggesting there hasn't been a general trend toward less aggressive end-of-life care.

"It shows that we're not yet providing the type of care in the place of care that necessarily may be what people most want," said Dr. Mary Tinetti of the Yale School of Medicine in New Haven, Connecticut, who co-wrote a commentary published with the new study.

Researchers led by Dr. Joan Teno at Warren Alpert Medical School of Brown University in Providence, Rhode Island reviewed Medicare claims data for more than 800,000 seniors who died in 2000, 2005 or 2009.

During that span, the proportion of people who died in the hospital fell from about 33 percent to 25 percent. Use of hospice - which focuses on controlling pain and helping a patient die in comfort - rose from 22 percent to 42 percent at the time of death.

That finding is in line with research from the Centers for Disease Control and Prevention, which showed an increase in the number of elderly people dying at home between 1989 and 2007.

But Teno's team also saw a bump in the number of transitions between healthcare settings made in the last three months or three days of life. And the proportion of seniors with an ICU visit during their final month rose from 24 percent to 29 percent, the researchers reported Tuesday in the Journal of the American Medical Association.

"This study does point out the increase in referral to hospice, which is a good thing," said Dr. R. Sean Morrison, a palliative care researcher from the Mount Sinai School of Medicine in New York.

"The bad part about it is it's happening very, very late," Morrison, who wasn't involved in the new research, told Reuters Health.

Part of the reason for that is likely the financial incentive for hospitals to provide more tests and more services, he said.

The findings suggest to Tinetti that patients, families and doctors are putting off end-of-life discussions until people are very sick in a time of crisis. When that happens, patients often end up in the ICU, getting every test and procedure that can be done - until there's nothing left to do and they're shuttled to hospice for their last few days of life.

"The whole concept of hospice is helping the patient, helping the family deal with that stage of life," Tinetti said - but it's not always being used that way.

"Our concern is, this pattern of hospice as an add-on to aggressive care during the last days of life, it's really only sensible if that's what the dying patient and their family wanted," Teno told Reuters Health.

She pointed to her own experience this winter of transporting dying patients to the hospice unit in sub-freezing weather, when they had less than 24 hours to live.

"I would suspect… that we're not achieving the goal of shared decision-making," Teno said. "I just want to make sure the services a patient gets are the ones they want."

Researchers said patients and their families should not be afraid to bring up their preferences for end-of-life care soon after the diagnosis of a serious illness - when there's plenty of time for discussion and planning.

That preference "is an ongoing process, an ongoing dialogue," Tinetti told Reuters Health.

"It needs to (start) as soon as someone knows that they have a disease that is likely to progress over the next few years."

SOURCE: http://bit.ly/JjFzqx Journal of the American Medical Association, online February 5, 2013.

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