Patients with end-stage renal disease are faced with a seemingly impossible dilemma as their health deteriorates: try to prolong life with continued treatment or seek end-of-life comfort through hospice.
Hospice care—covered by Medicare, Medicaid and most private insurers—is a benefit available to individuals with a life expectancy of six months of less. The way it’s currently set up, though, prevents Medicare from paying for dialysis and hospice at the same time, meaning patients receiving treatment for kidney failure have to stop life-prolonging care in order to receive hospice services known to boost comfort, improve bereavement outcomes and reduce medical costs.
The conundrum is not isolated to kidney-failure patients and has been an ongoing thorn in the side of hospice advocates and industry representatives.
“It is an absolutely shame that people have to give up so-called curative in order to get palliative care, hospice,” Edo Banach, CEO of the National Hospice and Palliative Care Organization, previously told Home Health Care News. “It shouldn’t be a choice.”
Having to halt treatment for hospice is significantly more prevalent among kidney-failure patients, who, depending on kidney function, can live anywhere between several days and a couple weeks without dialysis, according to the National Kidney Foundation.
Perhaps unsurprisingly, that difficult choice has contributed to patients with kidney failure using hospice far less than others, a new study has found.
Nationally, about 20% of Medicare patients with end-stage renal disease use hospice prior to death, according to the study, published last week in Jama Internal Medicine. In comparison, about half of all people on Medicare who die receive hospice care.
“Patients with kidney failure are much less likely than people with other conditions to get into hospice in time to reap the benefits hospice has to offer in terms of improving quality of life,” Melissa Wachterman, the study’s lead author and a physician at Brigham and Women’s Hospital in Boston, told HHCN. “This may be, at least in part, due to the fact that Medicare won’t pay for hospice or most patients with kidney failure until they stop dialysis—and once people stop dialysis, most die within a week or so.”
As part of the study, Wachterman and researchers looked at a 14-year window of more than 770,000 Medicare claims, plus data from the United States Renal Data System, a national registry that collects, analyzes and distributes information about end-stage renal disease. Registry data specifically linked back to individuals who had both Medicare parts A and Part B.
In addition to using hospice less frequently, Medicare patients with end-stage renal disease also used hospice for shorter periods, the study found.
Of all people on Medicare who died while receiving hospice care, the median length of stay was 23 days, with an average of 70 days. When dialysis patients stopped treatment and entered hospice, however, their stays often only lasted two or three days.
“They’re not referred to hospice, many of these patients, until they are within days of death—sometimes even the day of death,” Ann O’Hare, senior author of the study and a professor of medicine at the University of Washington School of Medicine, told HHCN. “A lot of times, [patients] are only offered hospice as a last resort when everything else has already been tried.”
Having the ability to stop dialysis, enter hospice and better control the timing of death can be “a blessing” for some people, O’Hare said. Others, though, might prefer to enter hospice while still receiving dialysis treatment, which could help provide symptom relief for things like fluid buildup.
In general, longer hospice stays lead to lower overall care costs, the study also found. That’s not the case when it comes to kidney-failure patients who are only in hospice for a handful of days.
“For these patients, presumably, there really is no cost savings,” O’Hare said. “There is no appreciable difference in what happens to them at the end of life… sort of too little too late.”
The study was partially funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases. Support was also provided through career development awards from the National Palliative Care Research Center and the National Institute on Aging.
Written by Robert Holly