End-of-Life Choice, Palliative Care and Counseling

Editorial: Dementia-care study troublingby Sonja

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The Sarasota Herald Tribune
October 3, 2011

A new study, focused on medical interventions among dying dementia patients, raises disturbing questions.

The study suggests that shuffling late-stage patients from nursing homes to hospitals and back raises government costs yet often fails to provide benefits that outweigh the risks.

Study authors said many patients would be better off staying put in a supportive nursing home, receiving palliative care that provides relief from pain linked to illnesses.

The study was published Thursday in the New England Journal of Medicine. Reportedly, it provided no evidence that the hospitalizations of late-stage dementia patients were financially motivated.

Yet it’s difficult to ignore the possibility. A nursing home gets lower government reimbursements for Medicaid patients (receiving custodial care) than for those who qualify for Medicare coverage at a skilled nursing facility following hospitalization.

“If you have a nursing home that is operating on a margin, it adds up. It can be a tremendous incentive to hospitalize these people,” the AP quoted Dr. Joan Teno as saying. Teno, a palliative care doctor and health policy professor at Brown University, is one of the study’s co-authors.

They analyzed 2000-to-2007 Medicare data, looking for such patterns as “multiple hospitalizations in the last 90 days of life” among cognitively impaired nursing home patients. The authors dubbed such interventions — which in some cases included the insertion of feeding tubes for people who could no longer swallow — “burdensome transitions.”

The research covered nearly half a million people, 19 percent of whom “had at least one burdensome transition,” according to a summary posted on the journal’s website. “In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk.”

The tendency to hospitalize varied widely by region, from 2.1 percent in Alaska to 37.5 percent in Louisiana.

Often, the illnesses prompting these hospitalizations — such as pneumonia, urinary tract infection, or dehydration — could be treated at a well-equipped nursing home. But Medicare and Medicaid payment policies don’t encourage that approach.

When it comes to end-of-life care, of course, decisions are rarely clear cut or easy. Painful ambiguity surrounds the entire subject.

A nursing home may send a patient to the hospital rather than take the risk — of injury or lawsuits — of trying a more conservative approach at its own facility.

In an editorial accompanying the study report, the journal points out a shortage of professionals trained in geriatrics. It notes that not all nursing homes “have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population.”

The study results affirm the need for families to discuss their care preferences — long before a crisis — and prepare for end-of-life decisions by completing “living wills” and other important documents.

The data also suggest that reducing preventable hospitalizations — a tenet of the national Affordable Care Act — holds promise for lowering costs and improving outcomes.

Though much of the Affordable Care Act is locked up in litigation, outcome-based research is moving forward.

That’s good. Judging by the new study results, there is no time to waste.