Abstract
Have you seen the trash chutes along the sides of buildings undergoing renovation? They are usually round and made of plastic. You can pitch the rubble from the 34th floor, and it tumbles quickly, and without creating much dust, to the ground floor where it pops out into the trash bin.
Have you seen the premier boarding lines at the airport? While most people are crowded and have to wait a long time to board their plane, selected people can move to a ‘special’ lane where they are whisked on board, often over a red carpet.
When I first began working in a freestanding inpatient hospice unit, I found myself wondering whether there was a premier boarding line for discharge to hospice care (the right care at the right time for the right patient). Or, more cynically, was there a virtual trash chute attached to each hospital in town—with the openings at the front doors of the inpatient hospice. Patients seemed to start popping out between 3 and 6 pm (before hospital change of shift). Patients and their families frequently looked bewildered, not sure where they were or how they got there. It was not unusual for them to say, “hospice….HOSPICE…. NO ONE EVER TOLD ME I WAS GOING TO A HOSPICE.” From David Casarett's work,1,2 that fits—patients rarely make the choice about hospice care. So, the allegory of trash chute fits the observations better than premier boarding line.
Our unit, like most units, was built with the expectation that a small number of people cared for at home by the hospice program would need to be admitted. In contrast, nearly since the day of opening 20 years ago, about 50% of all admissions are transfers from local hospitals. Colleagues with similar units say they see similar things. Discussed in this issue, the National Inpatient Sample (NIS) databases for 2000-2009 were queried for hospitalizations that resulted in transfers to hospice and death in the hospital. Yearly totals, as well as demographic and clinical features, were tabulated for patients admitted to hospice units. These characteristics were also compared with hospitalizations that ended with death. Not surprisingly, the number of hospital to hospice unit admissions increased 15-fold from 27,912 in 2000 to 420,882 in 2009. The median hospital stay decreased, while the median age, proportion of sepsis disease related groups (DRGs), and proportion of Medicare hospitalizations increased. Lung, gastrointestinal, hepatobiliary, and brain cancer were consistently the most prevalent malignancy DRGs. However, the initial number of hospitalizations with any diagnosis of cancer was diminished by the end of the study.
Is this a good or a bad thing? Since we know that patients and families tend to view whenever they are referred for hospice care as the right time, 4 and we know that deaths with hospice care represent the best end-of-life care, 5 we should celebrate. More people are getting the ‘right’ care—even if it's brief. From a health care finance issue, it's a bad thing. The hospital gets the full amount of money for the hospitalization. Further, they don't get ‘dinged’ for a hospital death in their quality measures. Conversely, the hospice pays for a ‘short stay’ that is expensive; the direct admission from the hospital is not the patient for which the Medicare Hospice Benefit was designed. It is also rough on everyone—but is it the right thing to do? Is it a dump? Or is it the red carpet to the best care? As palliative care in hospices moves from ‘choice’ to ‘the completion of good medical care,’ this is one of the patterns for which we will need to decide if it is good or bad.