Studies say access to hospices improves end-of-life care

WASHINGTON–As Sarah Palin cranks up her “death panel” charges ahead of November’s elections, new studies suggest that the health care reform law will improve end-of-life care.

Palin has revived the notion that the reform bill includes mechanisms to deny care for the the sick and elderly, part of an election-year bid to defeat Democrats who supported the overhaul.

But the law never included any such provision. And in fact, the health reform measure aims to make some potentially significant, if incremental, improvements to end-of-life care, chiefly by increasing access to hospice programs.

New research confirms the benefits–financial, physical, and emotional–of choosing hospice care over aggressive curative treatments for people facing life–limiting illnesses such as cancer, heart disease, or dementia.

Hospice services, also referred to as palliative care, focus on controlling a patient’s pain and symptoms, rather than on medical treatments to cure them. Hospice care usually allows such patients to stay at home, where they are visited by a team of health professionals, from doctors to social workers, who focus on reducing physical suffering and providing counseling services to help families cope with the emotionally wrenching prospect of death.

“There’s a point where chemotherapy and radiation makes you sicker,” said Carol Mahier, executive director of the Norwich-based Hospice of Southeastern Connecticut. “People can be treated to death … There’s a time and a place where less is more.”

A study published last week in the Journal of Clinical Oncology found that cancer patients who stopped hospice care were far more likely to be hospitalized, admitted to an emergency room or intensive care unit, and to die in a hospital than those who stayed in hospice. And their health care expenses were five times higher than those who stayed in hospice.

Another recent study, by the Dana-Farber Cancer Institute, found that cancer patients who died in ICUs or hospitals suffered more physical and emotional distress in their final days than those who died under hospice care. That analysis also found that caregivers of hospice patients had a lower risk of developing psychological strain stemming from their loved-ones’ death.

Experts say that until now, federal policies have failed to optimize access to hospice services, despite this growing body of evidence demonstrating the benefits.

Health care regulations for the dying “have been written in a way that’s not consistent with the human body,” by drawing a stark line between aggressive treatment and palliative care, said Elizabeth Bradley, a professor of public health at Yale University and one author on the Journal of Clinical Oncology study.

For example, Medicare, the government health programs for the elderly, only reimburses patients for hospice care if they agree to halt any curative treatments. But very often, Bradley said, patients need both.

Under health reform, some patients will no longer have to face the difficult decision of whether to halt treatment and instead opt for symptom and pain relief. Medicaid and the state-federal Children’s Health Insurance Program will now allow children who face severe illnesses to pursue both life-prolonging medical treatment and hospice care.

“No parent wants to make that choice of when it’s appropriate to forgo curative treatment and opt for hospice care,” said Christopher Santarsiero, a spokesman for VITAS Innovative Hospice Care, which has offices in Connecticut and elsewhere. He said the shift in pediatric care is sensible and “the right thing to do” for families.

The new law also calls on Medicare to set up 15 demonstration sites around the country where the elderly can also get both curative and hospice services, with the possibility of nationwide expansion if it proves successful. Santarsiero said Connecticut would be an ideal test site for a concurrent care project, both because hospice has deep roots in the state and because Connecticut residents still lag behind the nation in their use of hospice services.

The U.S. hospice movement began in Connecticut, imported from England in the mid-1970s by the late Florence Wald, the one-time dean of nursing at Yale University. Wald was a driving force behind the establishment of the first American hospice, the Connecticut Hospice in Branford, in 1974. Now, there are about 5,000 hospice programs around the country, including about 30 in Connecticut.

Some proponents say the new access to hospice services could make a big difference in both the quality and the cost of health care for people who are dying.

By offering the elderly concurrent care, “they will make some choices that will improve their quality of life and ultimately save the system dollars,” said Jon Radulovic, of the National Hospice and Palliative Care Organizations.

Dr. Diane Meier, director of the Center to Advance Palliative Care at the Mount Sinai School of Medicine, noted that two-thirds of Medicare spending is driven by the elderly who have five or more chronic conditions-in other words, people who could benefit greatly from palliative care services.

Given that, she said, the health reform bill “offers an enormous opportunity” to better integrate hospice and similar services into general medical practice. But she said it’s unclear whether federal health officials will have the political will to write regulations that push the health care system aggressively in that direction.

“It remains to be seen whether the political environment will prevent that from happening because of fears of labels, such as death panels and rationing,” Meier said. Such explosive terms have proven to have “sticking power,” she noted.

The death panel brouhaha first emerged last summer, when lawmakers were considering a provision to reimburse doctors for consultation sessions with Medicare patients about end-of-life care. The sessions were supposed to provide patients with information about living wills, hospice care, and other such issues.

Amid public confusion and anger, lawmakers quickly killed that Medicare reimbursement proposal. But misperceptions that health reform will allow the government to “pull the plug on grandma” have persisted. One recent public opinion survey, conducted by the nonpartisan Kaiser Family Foundation, found that half of all seniors either believe the law includes a “death panel” provision or they are unsure if it does.

The end result, several experts said, was a relatively modest bill that opens some new opportunities but leaves a lot of uncertainly as well.

If the modest changes included in the health reform law are successful and expanded, said Yale’s Bradley, “that would be transformational.”