Although the hospice program was originally designed for cancer patients, who are expected to die within six months, about half of the older adults enrolled are currently diagnosed with dementia.
Now, a new study by researchers at UC San Francisco and the Icahn School of Medicine in Mount Sinai shows that patients with dementia with dementia are more likely to receive excellent care and control their anxiety and sadness than those with dementia. who are not in the hospice. However, eligibility criteria mean that some patients with dementia face barriers to accessing the hospice or may be at risk of dropping out.
In the study, published in Health Affairs on June 6, 2022, researchers tracked Medicare claims and data from the National Study of Health and Aging Trends of 2,059 seniors over the age of 70, who had died between 2011 and 2017. 40% of these elderly people (951) had dementia, of which 59% used the hospice, which is defined as regular visits by nursing staff, social workers and chaplains provided in the patient’s home, assisted living center, nursing home, or dedicated area within an independent hospital or hospice. Of the 60% of seniors (1,108) without dementia, 43% used hospice.
The researchers compared the quality of care during the last month of life between hospitalized dementia patients and non-hospitalized dementia patients, questioning their “attorney,” a spouse, or an adult child care provider. most cases, after the death of the patient.
About 52% of hospice collegiate attorneys said the standard of care was excellent, compared to 41% of non-hospice enrollment attorneys. In addition, 67% of hospice affiliates ‘attorneys said their sadness and anxiety were managed, compared to 46% of non-hospice enrollees’ representatives. The results also showed that hospice enrollees were less likely to switch to a different care setting than non-hospice enrollees in the days before their death: 10% versus 25%.
Equal impact of hospital care for patients with and without dementia
When comparing indirect hospice assessments for patients with dementia with patients with other conditions, the researchers unexpectedly found that the impact on the quality of care was about the same.
First author Krista L. Harrison, PhD, an associate professor in the UCSF’s Geriatrics Division and a health services researcher, said she was surprised by the finding.
Honestly, we expected it not to be positive. Because the hospice model was designed for cancer patients, we expected end-of-life care to be worse for people with dementia. “
Krista L. Harrison, PhD, Associate Professor, UCSF
In addition, previous research indicates that patients with dementia are also at risk of discharging, in which care is canceled due to insurance reimbursement criteria that require documentation of continuous decline, to say. At the other end of the spectrum, concerns about cancellation of enrollment may mean that patients with dementia are less likely to benefit fully from the hospice and enroll too late, if they do so, say the researchers.
The philosophy of the hospice assumes that the dying person can participate in decision-making and that family members provide care between visits by the hospice team. But to be eligible for the hospice with a primary diagnosis of dementia, enrollees must be “unable to speak and need help with almost every activity in daily life,” Harrison said. Therefore, their needs exceed the help often available through the Medicare hospice model, leaving gaps for family, friends, or paid caregivers.
Hospice policies should conform to “unpredictable dementia trajectory”
The hospice model “can lead to reduced access and paradoxically long stays and high rates of discharge while still alive,” said co-author Lauren Hunt, PhD, RN, FNP, nurse and health services researcher at UCSF. “Hospice policies could be changed to better suit the unpredictable trajectory of dementia,” he said. Harrison added that care during the last month of life may not seem different from the previous six months until the last days. Many people with dementia die from conditions that can increase rapidly, such as a bladder infection or pneumonia. (Although researchers did not quantify enrollment dropouts in this study, a 2020 survey found that in the San Francisco Bay Area, 20.2% of those enrolled in hospitals with dementia were discharged before death, compared with 13.9% of cancer patients.)
In theory, enrollees are entitled to an unlimited number of days of hospital care, the researchers say. But in reality, “regulatory changes and increased oversight” mean that many hospice organizations are reluctant to enroll patients with dementia for more than “near-death care” for fear of not be able to document the continuous decline required for eligibility and insurance. refund. According to Harrison, “sick leave may seem like an abandonment because there are few suitable alternative models of near-death care for people with dementia.”
The finding that the hospice significantly benefits those with dementia underscores the need to ensure access to high-quality end-of-life care for this growing population, he said. “Future work should examine whether removing the prognostic requirements for hospice eligibility for people with dementia positively affects timely access and quality of care.”
Source:
University of California – San Francisco