The report found some positive trends toward less aggressive end of life care: The number of median days in hospice care during the last 30 days of a person's life went from 3.3 in 2000 to 6.6 in 2009, and many more patients were enrolled in a hospice program at their time of death, from 21.6% to 42.2%. Also, a slightly higher percentage of patients had continuous hospice care in their last month of life.
It appears, however, that more patients are spending fewer than four days in hospice settings before their death, indicating that the hospice option may be offered too late for some.
Another finding is that more patients spent time in hospice units within general inpatient hospitals in 2009 than in 2000. "I guess that's good," Teno says, "but my concern is that the use of these services really come only after an aggressive pattern of care. Hospice has become sort of an add-on with these people who spend three days or less on hospice services."
The researchers' sample used a cohort of a random 20% sample of fee-for-service Medicare beneficiaries who died in 2000, 20005 or 2009 and who were 66 years or older, and did not have health insurance coverage.
The Residential History File that assigns Medicare beneficiaries to a given location each day was used to determine place of death, number of healthcare transitions, and places of care.
An accompanying JAMA editorial by Grace Jenq, MD and Mary Tinetti, MD, of the Yale School of Medicine and the Yale School of Health suggest that a solution might be a policy in which physicians and others set "criteria for ICU admission as for other sites of healthcare (which) could reduce inappropriate and costly ICU stays that deprive many patients of the end-of-life care they would prefer if asked.
"Perhaps there should be a threshold of likely benefit and life expectancy or an ICU admission," they wrote. "Elicitation and documentation of goals of care and a plan detailing how intensive care is the optimal method for meeting those goals should be required to receive reimbursement or ICU care."