Study finds room for improvement when hospital patients transition to hospice care
Terminally ill patients referred to hospice care from a hospital setting tend to be on hospice for shorter periods than those who enter hospice while living at home or in a residential care facility.
The findings by Oregon State University College of Pharmacy researchers are an important step toward improving the care experiences of dying patients and their loved ones.
Hospice care refers to treatments whose goal is to maximize comfort and quality of life as opposed to prolonging life. In general, more time on hospice is better for patients than less time, research has shown.
"It's well established that hospice care reduces symptom burden and improves quality of life for patients nearing the end of life and for their caregivers," said the study's lead author, Jon Furuno, an associate professor and the interim chair of the Department of Pharmacy Practice. "Patients receiving hospice care also have their discomfort controlled better and experience more satisfaction with their care compared to patients who die without receiving hospice care."
But Furuno's recent research, published in the journal Medical Care, points out some key variations in hospice transitions and experiences, opening the door to changes that could make important, positive differences for patients and families.
Patients can be referred to hospice care from any location, Furuno explains, but little is known about differences between referrals from different care settings; i.e. hospitals, nursing homes, assisted living facilities or the someone's home.
"Are the patients enrolling in hospice at an appropriate time or later than ideal? Are they making the transition to hospice care with the right prescriptions from their providers? How do things differ among referral locations? Those are all key questions to explore to help ensure optimal patient care," Furuno said.
The study looked at data from nearly 80,000 adult hospice patients from 19 states over a five-year period. Their average age was 79, and one-third were receiving hospice care because of a terminal cancer diagnosis.
Just over half of the decedents had been referred to hospice from a hospital setting, and about one in five had been living at home at the time of their referral. Nursing homes (17%) and assisted living facilities (9%) rounded out the sample.
The results showed that hospital-referred patients were much less likely to receive hospice care before the final seven days of their life than patients referred from elsewhere; 56% of those referred from a hospital spent less than a week on hospice, compared to 30% from nursing homes, 29% from their own home, and 19% from assisted living.
"Obviously every case is unique, but generally speaking, more time in hospice care is associated with better patient and family outcomes," Furuno said. "In our study, the median length of time on hospice was nine days."
Another key finding involved drug prescriptions, particularly the absence or presence of a constipation-alleviating drug along with the opioids often used during hospice care. Opioids relieve pain but can cause other discomfort in the form of infrequent bowel movements.
"Hospital-referred patients had the lowest frequency of co-prescribed opioids and a bowel regimen," Furuno said, noting co-prescription of these medications is an important indicator in the Centers for Medicare and Medicaid Services' Hospice Quality Reporting Program.
Among hospital-referred hospice patients, fewer than 60% received that co-prescription compared to 72% of patients referred from nursing homes, nearly 70% from assisted living facilities and 63% from home.
"The study's results suggest an opportunity for interventions that will improve the transition to hospice care and benefit patients and families," Furuno said. "Patients transitioning from the hospital to hospice care may be the most vulnerable group because of the magnitude of the transition from actively fighting a chronic illness for months or maybe years to palliative care."
Also, health care providers in a hospital setting may not always be sufficiently trained in preparing patients and families to make that transition, he said, adding that further research should look for explanations behind the hospice transition differences uncovered by this study.
"The end goal is policies and practices that consider these differences and trigger specialized interventions when necessary so patients can get the best end-of-life care possible," Furuno said.