According to a new study published in the June issue of Health Affairs, half of adults over the age of 65 visited the emergency department at least once in their last month of life. In addition, three-quarters of those ED visits led to hospital admissions and more than two-thirds of those visitors died during their stay.
The study, which was lead by Alexander K. Smith, a palliative medicine doctor at San Francisco VA Medical Center (SFVAMC) and an assistant professor of medicine in the Division of Geriatrics at University of California, San Francisco (UCSF), found that in comparison, the 10 percent of study subjects who had enrolled in hospice care at least one month before death were much less likely to have made an ED visit or died in the hospital.
“We were interested in studying a simple question – how often is the ED used at the end of life?” explained Smith. “We know it’s not the best place for end-of-life care, but we didn’t know how often older adults were using it.”
According to Smith, the study was based on an analysis of health records of 4,518 people over the age of 65 who died while enrolled in the Health and Retirement Study, an ongoing nationally representative longitudinal study of health, retirement and aging, sponsored by the National Institute on Aging.
“It’s a cost-avoidance measure. The ED and hospitalizations are expensive. My take on it is that the primary goal is always to improve the quality of life for patients,” Smith said. “The traditional focus of the ED is stabilization and triage, not end-of-life care, while hospice provides care specifically for patients with a prognosis of six months of life or less."
Smith said that hospice care, which is free to everyone enrolled in Medicare, is centered on the treatment and relief of symptoms that are common near the end of life, such as pain, nausea, shortness of breath and confusion. The majority of hospice care is provided in the patient's home.
"The interdisciplinary hospice care team is very skilled at providing relief from other forms of suffering as well, such as spiritual and psychological pain," said Smith. "They also provide bereavement support for families before and after death."
[See also: Hospices fight Medicare cuts.]
To encourage timely enrollment in hospice care, Smith and the other authors of the study recommend that governments, health care systems and insurers institute policies that encourage physicians to discuss end-of-life care with patients and their families, including reimbursement for advance care planning.
“We need to do a better job in the outpatient setting when it comes to patients nearing the end of their lives,” he said. “We need to encourage physicians to have these discussions and perhaps provide incentives to them. As a side effect, doing all of these things may reduce costs to hospitals.”
Smith said that despite preparing older adults for hospice care, there will be many patients that still go to the ED.
“Sometimes the ED is the best choice for certain people,” he said.
The co-authors of the study are Ellen P. McCarthy, of Harvard Medical School and Beth Israel Deaconess Medical Center (BIDMC) in Boston; Ellen Weber, of UCSF; Irena Stijacic Cenzer and W. John Boscardin, of SFVAMC and UCSF; Jonathan Fisher, of Harvard Medical School and BIDMC; and Kenneth E. Covinsky, of SFVAMC and UCSF.