End-of-Life Care Patterns

End-of-life care is often singled out as a contributor to high health spending and as a source of overly-aggressive, inappropriate care.  A study in Health Affairs studies patterns, and changes in those patterns, of end-of-life care.   (HA Article)   In 2015, 2.7 million Americans died.  Average age expectancy in currently about 79 years, with women expected to live about 5 years longer than men.  Among leading causes of death, heart disease, the single largest source, has experienced a decline in the last decade, while cancer has shown a slight increase.  These are far and away the two largest causes of death.  Other diseases, like stroke or pneumonia, have declined as a source of death, while Alzheimer’s is rising rapidly.  As the population ages, increasing numbers of people have multiple chronic and/or serious diseases at the time of death, which in itself probably contributes to greater spending in the last year of life.  Of the group in the US with the highest annual health spending, only 11% are in the last year of life, but they are usually patients with multiple morbidities.

Caring for these individuals is complex for clinicians and imposes substantial burdens on informal caregivers such as families and friends.  The complexity of their care means there often is uncertainty as to an optimal treatment pattern and frequently raises issues regarding futile treatment.  While most people say they want to die at home and to avoid expensive, lengthy hospitalizations near the end-of-life, about two-thirds have at least one hospitalization in the last 6 months of life and a quarter have multiple stays.  A large percent end up in an ICU and there are frequent transitions in care sites, which adds to the burden on the patient and on informal caregivers.  Quality of life undoubtedly is lessened from these hospitalizations and care transitions.  Even people in hospice care often end with ER visits or hospitalizations.  Hospice use has grown greatly, going from a setting used primarily for cancer patients to one that has a wide diversity of diagnoses.  Many of these patients have relatively long hospice stays, as their diagnoses has a less predictable trajectory than cancer usually does.  There has been a shift in the percent of people dying in a hospital to dying at home, but although the site of death has changed, there still appears to be fairly heavy care use before death, regardless of where the death occurs.  While there has been a focus on determining patient wishes and limiting aggressive care, there appears to be work left to limit end-of-life care as a source of high spending and spending growth.