End-of-Life Care and Place of Death

Many people are sick at the end of their lives, and most would prefer to die at home with family and friends, in a familiar place.  For some time research has indicated a better quality of life for those who are able to cared for at home or in another place such as a hospice, but it is not clear that medical care has actually moved more in this direction.  Research in the  Journal of the American Medical Association looked at place of death and other aspects of end-of-life care for Medicare beneficiaries in 2000, 2005 and 2009.   (JAMA Article)    The researchers found that more beneficiaries were indeed dying at home and outside of the hospital, including those who have cancer and dementia.  But most were still not dying at home, they were increasingly dying in hospices.  The use of hospice services at the time of death increased from 22% in 2000 to 32% in 2005 to 42% in 2009.  But many of these stays were very short and many were preceded by time in a hospital ICU.

And notwithstanding the decline in hospital as the place of death, there was an increase in hospitalizations in the last 90 days of life, from 63% in 2005 to 69% in 2009.  Nursing home admissions also increased slightly.  The number of transitions in location of care increased by 50% from 2000 to 2009 and these transitions are hard on the beneficiaries, their families and the system.  Given these statistics, it is unclear that the quality of end-of-life care is actually improving, in fact it may be worse as patients are moved around from hospital to nursing home to hospice.  And a short stay in the hospice before the patient dies is no indicator of delivery of extensive palliative care geared toward making the end-of-life more bearable for the patient.  And you have to wonder if there isn’t some financial benefit to the providers in this evolving pattern of care.