Wednesday, February 6, 2013

When Does End of Life Begin: Implications for Hospice Medicare Policy

News Video: When Does End of Life Begin: Hospice Under Scrutiny

The government is examining whether the 6 month prognosis for hospice eligibility is appropriate, or whether it should be extended. The hospice medicare reimbursement and eligibility structure is antiquated and inappropriate for modern chronic illness care. It's high time that this policy is examined and updated 

Despite the many attempts to develop prognostic tools that work in HF, we still cannot accurately predict when people with chronic illness will die. We've known this since the late 1990s when the SUPPORT study was published. At the same time, people with heart failure and other end-stage chronic illnesses derive tremendous benefit from the hospice model of care with outcomes including reduced hospitalizations and improved QOL, To me, these are not just statistics- I've seen this in my dad and mother-in-law, both of whom died of end-stage heart failure, and who each received hospice services for the last 5-6 months of their lives. In each of them, hospice prevented several hospitalizations. At the same time, we had the ongoing support needed to closely follow them and provide the support we needed. And both died suddenly, with no indication that 24 hours later they would be gone.

Hospice-model care during the final year of life in chronic illness can save the government money by reducing the costs of expensive hospitalizations and interventions in the last year that are often futile and fraught with complications, as these individuals are very frail with multiple comorbidities. The costs of hospital-based care for these individuals are not just financial. For the patients and their families, these costs include pain, fear and anxiety, loss of control, physical and mental exhaustion and frustration- at a time when they are already stretched to their limits. Is it any wonder that patients and families who have been through multiple hospitalizations and near-death experiences would delay seeking care when they know it's going to be like this again? During my Dad's last year, when he had to go into the ER, he would cry out with frustration and despair, and I would just cringe inside- knowing what I needed to do, but wishing that there was some other option.

We need to weigh in on these policy processes, advocating for a more appropriate hospice benefit, that fits the trajectory of end-stage chronic illness, and that will promote quality at the end of life for all Americans.

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