Yale: Hospice Patients Are Admitted Too Late

Half of patients admitted into hospice care are admitted only within the last two weeks of their life, according to a recent study from Yale University physicians. This timeframe undercuts the hospice benefit, which can extend for six months, and reveals some of the challenges related to seniors in the last stage of their life.

In addition, many of the patients admitted within the last few weeks of their lives had experienced symptoms related to their conditions for weeks or months prior.

Late Arrivals

Yale researchers observed 562 decendents who died between 1998 and 2014, 43.4% of which were admitted into hospice, according to the study, “Distressing Symptoms, Disability, and Hospice Services at the End of Life: Prospective Cohort Study,” which was published in the Journal of the American Geriatrics Society on Tuesday.

“The good news is that hospice is used commonly—almost half of the persons who died,” Thomas Gill, MD, lead author of the study, told Home Health Care News. “The bad news is it is used often only at the very end, in the last few weeks, of life. That diminishes the possible benefit of hospice.” Gill is also a professor of medicine, epidemiology and investigative medicine and the Humana Foundation professor of geriatric medicine at Yale University.

The benefit, which was created in 1982 and can apply for a six-month period, is underutilized to relieve symptoms of a terminal diagnosis.

Based on prior research, the Yale team was surprised to find that patients’ symptoms had an influence on hospice admission, with cancer and advanced dementia as the most common conditions for hospice admission.

“The condition that is more predictable is cancer; that’s why it’s used more for cancer than other conditions,” Gill explained.

However, even these patients are admitted late, with half of study participants having a duration of less than 13 days.

“We’re not talking about half the patients who were in for two or three months,” Gill said. “Half were only two or three weeks—a long way from six months.”

While cancer patients might be more likely to be admitted to hospice earlier, as the disease can be somewhat easier to predict, it’s much harder to pinpoint when death is near in dementia patients. And symptom descriptions often come from proxies rather than patients themselves, who can be debilitated by the disease.

End-of-Life Discussions 

A big part of the admissions issue is that the conversations needed to discuss quality of life are simply tough ones to have. Families, patients and doctors need to make hard decisions based on a person’s preferences and conditions. The situation is a deeply personal one.

“It’s challenging and difficult to have honest discussions with patients and families about end-of-life care,” Gill said. “Issues related to death and dying are always challenging. …If it’s framed properly, patients are often thinking about their death and many would welcome an honest discussion. It’s a matter of breaking through those preconceived notions.”

Outside of hospice care, stakeholders—and even artists—are working on bringing these discussions to the forefront of care, and doctors can even be reimbursed for having end-of-life care talks with patients.

However, they are still happening too late, based on the study results, Gill said.

As most hospice is offered at home, admitting seniors sooner to the benefit could actually save on costs down the road by preventing hospitalizations and relieving symptoms.

“It’s a matter of thinking about hospice sooner,” Gill said. “Most hospice is provided in the home, and it doesn’t require a lot of doting resources. …Many persons in the last phase of their life don’t want to spend a lot of time in the hospital, they want to be home. …Using hospice sooner is not necessarily more costly to society or to the Centers for Medicare & Medicaid Services (CMS).”

Written by Amy Baxter