Delayed hospice care common for dialysis patients

(Reuters Health) - Very few Medicare patients on dialysis receive hospice care at the end of life, and when they do, they’re often enrolled too briefly to fully benefit from these services, a U.S. study suggests.

Medicare, the U.S. health insurance program for the elderly that also covers Americans with kidney failure, will not pay for dialysis and hospice at the same time. This forces terminally ill patients to choose between continuing on dialysis or accessing hospice care, which may provide more comfort and support at the end of life, researchers note in JAMA Internal Medicine.

For the current study, researchers examined data on more than 770,000 dialysis patients covered by Medicare who died between 2000 and 2014. Overall, just one in five were receiving hospice services when they died.

Among patients who did receive hospice care, 42 percent were enrolled for three or fewer days. Compared with dialysis patients who didn’t receive hospice care, those enrolled in hospice for three or fewer days were more likely to have been hospitalized or admitted to intensive care units (ICU) in the last month of life. But they were less likely to die in the hospital or undergo invasive procedures.

“We found that people on dialysis who did enroll in hospice spent much less time in hospice than patients with other serious illnesses like cancer and heart disease, and those who did spend more time on hospice had lower healthcare costs,” said lead study author Dr. Melissa Wachterman, a researcher at Harvard Medical School and Brigham and Women’s Hospital in Boston.

Hospice is a benefit typically available to people with a life expectancy of six months or less. People in hospice generally stop active treatment and instead receive care focused on comfort as well as emotional support for patients and their loved ones.

Terminal kidney failure patients can have intense pain and worse quality of life than people with cancer or dementia at the end of life, Wachterman said by email.

“Patients with kidney failure stand to benefit greatly from the care hospice has to offer and yet they are about half as likely to receive hospice as those with other serious illnesses like cancer and heart disease,” Wachterman said.

One goal of hospice is also to avoid costly and often unnecessary interventions that don’t improve quality of life or extend longevity for people with terminal illnesses.

In the current study, average Medicare costs over the last week of life were similar for dialysis patients who didn’t go to hospice and those who enrolled only for three or fewer days before they died. Without hospice, the tab came to $10,871 compared with $10,756 with a brief hospice stay.

But when patients spent more than 15 days in hospice before they died, average Medicare costs over the final week of life were $3,221.

Just 35 percent of these patients who had longer hospice stays were admitted to the hospital in the last month of life, compared with 84 percent of people with three or fewer days in hospice.

“Any use of hospice greatly improves the opportunity to avoid dying in a hospital,” said Dr. Laura Hanson of the palliative care program at the University of North Carolina Chapel Hill.

“However, patients who enroll in hospice earlier are also avoiding intensive care and hospital stays in the month prior to death,” Hanson, who wasn’t involved in the study, said by email. “Accepting hospice earlier allows patients to make additional choices about their care.”

Still, transitioning from dialysis to hospice is a wrenching decision for patients and families, Hanson said.

“It takes courage,” said Dr. S. Vanita Jassal, director of geriatric and palliative renal care at the University Health Network in Toronto.

“Patients have often been coached not to miss a session or they could die,” Jassal, who wasn’t involved in the study, said by email. “We also don’t talk about death and how it is inevitable; we often don’t empower our patients to tell us when enough is enough.”

SOURCE: and JAMA Internal Medicine, online April 30, 2018.