Unpredictable death excludes patients
Unpredictable death excludes patients
With debate over physician-assisted suicide and other end-of-life issues escalating, a new study says that most Americans will not be able to benefit from hospice care because current Medicare regulations that require a six months or less to live diagnosis are too difficult for physicians to meet. Doctors simply cannot predict who will die within six months.
A team of researchers led by Ellen Fox, director of the National Center for Ethics of the Veterans Health Administration, analyzed the care of 2,607 patients with advanced stages of heart, lung, and liver failure. Their results showed that the timing of death for patients with these illnesses is unpredictable, making it difficult and often impossible to comply with the requirement of a six-month life expectancy.
Their results were published in the Nov. 4 issue of the Journal of the American Medical Association.
Researchers applied various sets of criteria to medical record information to find the patients that might be expected to die soon enough to be appropriate for hospice. The most inclusive set would have made hospice available to just 42% of the patients who actually died within six months, the time standard Medicare uses to determine hospice benefit eligibility. Some criteria would have allowed enrollment of just 1% of those who actually went on to die.
The unavailability of hospice care, often blamed on physicians’ reluctance to make a terminal diagnosis, is more a function of the unpredictability of the illnesses themselves. The study shows that the timing of death for patients with these illnesses is quite unpredictable. This unpredictability does not arise from physicians being reluctant to make forecasts or from an inattention to the symptoms. Rather, it is an essential part of the illness itself.
The study pointed out that no one could predict with certainty when specific patients are going to die. Any specific patient is likely to have had at least a 50-50 chance of surviving for six months within the time that turns out to be the last week or two of life, the study concluded. "Patients with these diseases — heart, lung, or liver failure — are very ill every day, yet some can survive a long time," Fox said. "Whenever such a patient gets an infection, or has a stroke, or anything else that stresses their fragile body systems, that patient is likely to die soon. However, it is difficult to predict when that last challenge to survival is likely to happen."
Joanne Lynn, director of the Center to Improve Care of the Dying at George Washington Univer-sity in Washington, DC, and co-author of the study added: "Virtually all of the patients in our study were very sick and facing the prospect of life coming to an end at any time. Virtually all of them needed symptom relief, continuity, home care, advance planning for complications, support of family, and attention to spiritual issues. In our system, that kind of comprehensive, end-of-life care is available only in hospice. Yet, no strategy can make hospice available to these patients because of the current requirement of six months prognosis.’ That seems unfair. We provide care only for those with convenient timing, and not for those with similar needs, but unreliable timing."
The Medicare hospice benefit began in 1983 and included various strategies to limit the risks of escalating costs. The prognostic requirement has proven to be the most onerous and contentious, according to end-of-life experts who advocate quality improvement in care for the dying.
About 70% of the more than 2 million Americans who die each year are covered by Medicare or Medicaid, and the federal government pays for about 80% of all hospice care delivered in the country each year. Yet only about 15% of the dying receive hospice care. Federal officials have raised concern over Medicare fraud in recent years, blaming doctors for certifying hospice care to patients whose illnesses were not terminal and who lived far longer than six months.
But hospice industry officials say those cases were rare, and they point out that only 15% of patients receiving Medicare benefits survive longer than six months. Advocates for better care of the dying say the Medicare rules serve to exclude tens of thousands of people from hospice care who might benefit from the support services.
One avenue for reform, supported by Last Acts, a Robert Wood Johnson Foundation-funded organization, is to reduce reliance on the requirement of a short prognosis and allow hospice growth to be limited more by the other cost controls in the original statute. Last Acts officials also say relaxing the requirement to include all those who are just "more likely than not" to die within six months.
The Center to Improve Care for the Dying has been working on a more sweeping reform known as MediCaring. Their initiative would create special funding and regulations tailored to the care of these patients. The services would be similar to hospice services in many ways, but would serve patients with "serious and complex illness" who do not have a clear "terminal" period.
Proponents of the proposal say the services provided would generally be less intense than hospice, but more enduring, because some patients would live for a few years.
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