Providing hospice services in the last six months of life for nursing home residents does not increase costs, found a recent study. Some factors that can prevent or delay referrals include the following:

  • Starting the conversation is often difficult for providers.
  • There is often lack of clarity as to eligibility for hospice care.
  • Some enrollment policies restrict access to hospice.

Recent research debunks the myth that providing hospice services in the nursing home setting increases healthcare costs. In fact, use of hospice services does not increase care costs in the last six months of life for nursing home residents, found a study of 2,510 long-stay nursing home decedents, a third of whom received hospice services.1

The study’s finding suggests that costs are offset by the avoidance of costly hospitalization and subsequent post-acute care in the nursing home.

“The findings add to a growing body of research demonstrating the value of hospice care in providing both high-quality care and cost savings,” says David A. Fleming, MD, MA, MACP, director of University of Missouri’s Center for Health Ethics in Columbia.

A 2013 study linked hospice care to a reduction in hospital admissions and days, ICU admissions and days, 30-day hospital readmissions, and in-hospital deaths.2 Earlier research found that hospice reduced Medicare expenditures by an average of $2,309 per hospice user.3

Niharika Ganta, MD, MPH, assistant professor of clinical medicine at the hospital of the University of Pennsylvania Palliative Care Service in Philadelphia, says, “When hospice services are not offered, both patients and families are missing an opportunity to get valuable support during an often difficult and trying time.”

Delayed Referrals

Various factors prevent or delay referral to hospice. “Psychologically, death remains an avoidable reality for physicians and patients alike,” says Fleming. “With the amazing technologies and treatment options now available, hope for cure remains strong.”

Starting the conversation can often be difficult. Also, patients, families, and healthcare professionals are often unclear about eligibility for hospice care and the benefits it offers.

“Enrollment policies may restrict access to hospice,” says Fleming. Some patients are not eligible for hospice because they are receiving chemotherapy or blood transfusions.

Cultural and ethnic barriers, ranging from language differences to religious beliefs, can prevent substantive and effective communication about end-of-life issues. “For some historically underserved populations, there is often mistrust of the healthcare system,” adds Fleming. “There may be resistance to any suggestion of limiting what is felt to be potentially curative treatment, regardless of its futility.”

Ganta was surprised that only about a third of nursing home residents in the study received hospice care. “I would imagine that a larger portion of residents would qualify for hospice services,” she says.

In Ganta’s experience, the most common reason patients and families do not access hospice services is because they are not aware of the services provided. Many worry about extra out-of-pocket costs associated with more services.

Many people, including providers, feel nursing homes can adequately address and care for patients at end of life. “On the contrary, end-of-life care is a specialized field that requires a trained multidisciplinary team approach to provide holistic care for the patient,” says Ganta. “Nursing homes are not equipped to deliver such care.”

Fleming says the following things are needed:

  • development of clear, rational, and equitable enrollment policies,
  • effective education materials for patients and families,
  • outreach guides for ethnic groups and underserved populations, and
  • enhanced education and training curricula for healthcare professionals.

Clinical ethics consultants typically have specialized training and experience, making them well-positioned to mediate responses to the conflicts or concerns that often arise near the end of life, says Fleming.

“They offer important insights and guidance in decisions about hospice and end-of-life care, as well as in the development of policies and educational materials for patients, their families, and the healthcare team,” Fleming adds.

Not Fully Informed

If eligible patients are not offered hospice, whether intentionally or unintentionally, then by definition they are not being fully informed about the full complement of evidence-based options available to them, says Fleming.

“Withholding such information thwarts the notion of shared trust in decision-making,” says Fleming. This can result in decisions that are not fully informed, that are potentially coercive, and that disrespect the patient’s dignity and autonomy.

“To not offer comfort and care through hospice services and other means, while continuing aggressive and medically futile treatment when the patient is overmastered by their disease, is both unethical and unprofessional, knowing the harm to patients that may be inflicted,” says Fleming.

Support services offered by hospice range from support for spiritual distress to assistance with getting financial affairs in order. When hospice is not involved, “families are not able to easily access grief and bereavement counselors,” says Ganta. “Providers may feel burdened that they are not able to fully support patients at the end of life.”

Rosemarie Tong, PhD, emeritus professor of healthcare ethics at the University of North Carolina at Charlotte, says it’s important for patients to be aware that they have the option of comfort treatment only.

“The part of informed consent that currently speaks to patients’ ‘right’ to select no aggressive treatment is to be rephrased as a ‘right’ to select palliative care only,” she says.

Tong says hospice is not so much about dying as it is about living one’s life in the fullest way possible for whatever time one has left. “Not providing people information about hospice care deprives them of the time they need to repair human relationships,” says Tong. “It also deprives people of a meaningful opportunity to make sense of their life in view of death.”


  1. Unroe KT, Sachs GA, Dennis ME, et al. Effect of hospice use on costs of care for long-stay nursing home decedents. J Am Geriatr Soc 2016; 64(4):723-730.
  2. Kelley AS, Deb P, Du Q, et al. Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff 2013; 32(3):552–561.
  3. Taylor DH, Ostermann J, Van Houtven CH, et al. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med 2007; 65(7):1466-1478.


  • David A. Fleming, MD, MA, MACP, Director, Center for Health Ethics, School of Medicine, University of Missouri, Columbia. Phone: (573) 884-2013. Fax: (573) 884-1996. Email: flemingd@health.missouri.edu.
  • Niharika Ganta, MD, MPH, Assistant Professor of Clinical Medicine, Palliative Care Service, Hospital at the University of Pennsylvania, Philadelphia. Phone: (215) 478-2250. Email: Niharika.Ganta@uphs.upenn.edu.
  • Rosemarie Tong, PhD, Emeritus Professor of Healthcare Ethics, University of North Carolina at Charlotte. Phone: (704) 687-2850. Email: rotong@uncc.edu.