EXECUTIVE SUMMARY

ICU use in the last 30 days of life remains high but is not increasing, according to a recent study. Other findings:

• Fewer people died in hospitals.

• There were fewer burdensome transitions of care.

• Hospice use increased, with a reduction in late referrals.


Fewer people are dying in hospitals — and while ICU use in the last 30 days of life remains high, it is not increasing, according to a recent study.1

“There is striking reduction in patterns of transitions that we believe are burdensome to the dying persons and their family,” adds Joan Teno, MD, MS, the study’s lead author.

Transfers to different healthcare facilities during the last three days of life decreased from 14% in 2009 to less than 11% in 2015. “We have been doing this research for the past decade. We were surprised to see changes in the burdensome patterns of care,” says Teno.

Increased Hospice Use

The study was a follow-up to previous research published in 2013 that documented trends in end-of-life care.2 The previous study examined Medicare patient data between 2000 and 2009. Researchers found that during that time, more people were dying shortly after ICU stays, repeated hospitalizations, and experiencing burdensome transitions of care. The 2018 study examined a data set through 2015.

The Affordable Care Act (ACA) was enacted in between the two studies. One notable change is that Medicare Advantage now is caring for significant proportion of decedents. “With the passing of time and implementation of the ACA, we were interested in the secular trends,” says Teno, a professor of medicine at Oregon Health and Science University (OHSU) School of Medicine and a senior scholar at the OHSU Center for Ethics in Health Care in Portland.

Other key findings of the study, which compared Medicare fee-for-service beneficiaries who died in 2015 compared with 2000, include the following:

• Hospice use continued to increase, with a reduction in late referrals.

“Spending more than three days on hospice means that you can do more than just treat symptoms,” says Teno.2

• About one-third of individuals died in hospitals in 2000, but this decreased to 20% in 2015.

• ICU stays in the last month of life stabilized at 29% of patients since 2009.

Further research is needed to examine whether the changes in patterns of care reflect patients’ goals and values. “What is important is that care is consistent with patient-informed preferences,” says Teno.

Default: High-intensity Care

Hospital admissions decreased across all age groups, and ICU admissions decreased for patients over 65, found a recent analysis of 22,068 patients with chronic illnesses who died between 2010 and 2015.3

“We were interested in understanding the intensity of care at the end of life for patients with chronic, serious illness within our healthcare system,” says J. Randall Curtis, MD, MPH, one of the study’s authors.

Hospitalizations and ICU stays may be entirely appropriate at the end of life for some patients with chronic serious illness. “But we know that our healthcare system often defaults to high-intensity care at the end of life,” says Curtis. This is the case even when that care is not consistent with patients’ informed wishes.

The researchers developed a system within the electronic medical record to track these metrics over time. Less use of the hospital and the ICU in the last 30 days of life for patients with chronic serious illness was an encouraging sign. “The decrease is occurring over a time when our system has been focusing on improving palliative care and palliative care education throughout the system,” says Curtis, a professor of medicine and director of the Cambia Palliative Care Center of Excellence at UW Medicine in Seattle.

The study’s findings suggest that efforts to improve palliative care may reduce burdensome care at the end of life. “There is an ethical imperative to continue our work in this area,” says Curtis.

REFERENCES

1. Teno JM, Gozalo P, Trivedi AN, et al. Site of death, place of care, and health care transitions among U.S. Medicare beneficiaries, 2000-2015. JAMA 2018; 320(3):264-271.

2. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013; 309(5):470-477.

3. Sathitratanacheewin S, Engelberg RA, Downey L, et al. Temporal trends Between 2010 and 2015 in intensity of care at end-of-life for patients with chronic illness: Influence of age under vs. over 65 years. J Pain Symptom Manage 2018; 55(1):75-81.

SOURCES

• J. Randall Curtis, MD, MPH, Professor of Medicine/Director, Cambia Palliative Care Center of Excellence at UW Medicine, Seattle. Phone: (206) 744-3356. Email: jrc@u.washington.edu.

• Joan Teno, MD, MS, Professor of Medicine, OHSU School of Medicine, Portland. Email: teno@ohsu.edu