Am Fam Physician. 2010 Nov 15;82(10):1196.
Since its inception in 1982, the Medicare hospice benefit has allowed terminally ill patients to receive symptom oriented care at the end of life in a variety of clinical and home settings. Initially, hospice care included patients with terminal cancer, and subsequent prognostic criteria were developed for patients with terminal noncancer illnesses.1,2
The Medicare Payment Advisory Commission published a report in 2009 discussing the changing uses of hospice care in Medicare recipients.3 In 2006, nearly two thirds of deaths among hospice patients were related to noncancer diagnoses.4 The mean length of stay was 59 days, with less than 17 percent of patients receiving hospice care for more than 180 days.3 Despite improved awareness by physicians and patients' families of the availability of hospice services, 60 percent of Medicare decedents were not enrolled in hospice care at the time of death.3
Currently, patients with an anticipated life expectancy of less than 180 days are eligible for the Medicare hospice benefit. Most persons without cancer die of chronic debilitating illnesses, such as cardiovascular, pulmonary, or neurodegenerative conditions, and may require hospice care. Terminally ill, noncancer patients may rely on a subspecialist or the primary care physician to define goals of medical care, whereas oncologists often direct the care of patients with cancer.
Although there is no definitive study describing the economic benefits of hospice care, one study suggested that hospice intervention for the final 50 to 108 days of life provides the maximal Medicare savings.5 The study showed a savings of approximately $7,000 in patients with cancer and a savings of $3,500 in patients with other diseases. Beyond an economic impact, there are psychological benefits from timely hospice admission. The delay of interdisciplinary hospice care has been shown to worsen symptoms of depression for family members during the grieving process,6 and most Medicare beneficiaries do not wish to die in hospitals.7 This is congruent with a palliative care model for end-of-life care.
Physicians have a generally favorable opinion of hospice care, but many lack confidence in their knowledge of hospice practices.8 Better-informed physicians are more likely to recommend hospice care and successfully facilitate the transition of appropriate patients to a hospice program.9 This suggests a greater need among physicians, especially in the primary care community, to identify and establish goals of care for patients with advanced chronic illness who have limited life expectancy and may be hospice candidates.
Familiarity with the Palliative Performance Scale,2,10 Functional Assessment Staging for Dementia,2 and criteria of end-stage cardiopulmonary disease1,2 is essential for identifying terminally ill patients early enough to maximize the benefits of interdisciplinary hospice care. The use of these tools to evaluate prognosis is the Medicare standard by which hospices are held accountable. Physicians who are uncomfortable establishing palliative care goals can involve a specialist in palliative care.11
As the Medicare population expands with the baby boomer generation, the need for greater mastery of clinical and interpersonal skills regarding end-of-life care is essential for meeting the wishes and needs of patients.
Address correspondence to Marc G. Kaprow, DO, FACOI, at marc. firstname.lastname@example.org. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
1. Fox E, Landrum-McNiff K, Zhong Z, et al. Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. JAMA. 1999;282(17):1638–1645.
2. Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. 2nd ed. Arlington, Va.: National Hospice Organization; 1996.
3. Medicare Payment Advisory Commission. Report to congress. Medicare payment policy. March 2009. http://www.medpac.gov/documents/Mar09_EntireReport.pdf. Accessed August 2, 2010.
4. Centers for Disease Control and Prevention. National Vital Statistics System. Leading causes of death. http://www.cdc.gov/nchs/fastats/lcod.htm. Accessed June 22, 2010.
5. Taylor DH Jr, Ostermann J, Van Houtven CH, et al. What length of hospice use maximizes reduction in expenditures near death in the US Medicare program? Soc Sci Med. 2007;65(7):1466–1478.
6. Bradley EH, Prigerson H, Carlson MD, et al. Depression among surviving caregivers: does length of hospice enrollment matter? Am J Psychiatry. 2004;161(12):2257–2262.
7. Cosgriff JA, Pisani M, Bradley EH, et al. The association between treatment preferences and trajectories of care at the end-of-life. J Gen Intern Med. 2007;22(11):1566–1571.
8. Ogle KS, Mavis B, Wyatt GK. Physicians and hospice care: attitudes, knowledge and referrals. J Palliat Med. 2002;5(1):85–92.
9. Bradley EH, Cramer LD, Bogardus ST Jr, et al. Physicians' ratings of their knowledge, attitudes and end-of-life-care practices. Acad Med. 2002;77(4):305–311.
10. Lau F, Downing GM, Lesperance M, et al. Use of Palliative Performance Scale in end-of-life prognostication. J Palliat Med. 2006;9(5):1066–1075.
11. Needham PR, Newbury J. Goal setting as a measure of outcome in palliative care. Palliat Med. 2004;18(5):444–451.
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