Abstract
O'Hare AM, Hailpern SM, Wachterman M, et al. Hospice use and end-of-life spending trajectories in Medicare beneficiaries on hemodialysis. Health Affairs 2018;37:980–987.
Infrequent and late referral to hospice among patients on hemodialysis likely reflect the impact of a Medicare payment policy that discourages the concurrent receipt of these two services, but it may also reflect these patients' less predictable illness trajectories. Among a national cohort of patients on hemodialysis, the authors identified four distinct spending trajectories during the last year of life that represented markedly different intensities of care. Within the cohort, 9% had escalating spending and 13% had persistently high spending throughout the last year of life, whereas 41% had relatively low spending with late escalation, and 37% had moderate spending with late escalation. Across the four groups, the percentages of patients enrolled in hospice at the time of death were uniformly low, ranging from only 19% of those with persistently high costs to 21% of those with moderate costs, and the median number of days spent in hospice during the last year of life was virtually the same (either five or six days). The authors suggest that these findings signal the need for greater flexibility in the provision of end-of-life care in this population.
Wachterman MW, Hailpern SM, Keating NL, et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Intern Med 2018;178:792–799.
Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with healthcare utilization and costs. The objective of this cross-sectional observational study was to examine the association between hospice length of stay and healthcare utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis. The study was conducted through the United States Renal Data System registry. Participants were all 770,991 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were from April 2016 to December 2017. Results demonstrated that among the 770,991 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for three days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for three days or fewer were less likely to die in the hospital (13.5% vs. 55.1%; p < 0.001) or to undergo an intensive procedure in the last month of life (17.7% vs. 31.6%; p < 0.001) but had higher rates of hospitalization (83.6% vs. 74.4%; p < 0.001) and ICU admission (54.0% vs. 51.0%; p < 0.001) and similar Medicare costs in the last week of life ($10,756 vs. $10,871; p = 0.08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred >15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221). The authors conclude that overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within three days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. The authors further conclude that without addressing barriers to timelier referral, greater use of hospice may not translate into meaningful changes in patterns of healthcare utilization, costs, and quality of care at the end of life in this population.
Simkulet W. Informed consent and nudging. Bioethics 2018. [E-pub ahead of print]; DOI: doi.org/10.1111/bioe.12449.
To avoid patient abuse, under normal situations before performing a medical intervention on a patient, a physician must obtain informed consent from that patient. Moreover, the patient must give genuine informed consent, in other words, the patient must be competent, understand her condition, her options, and their expected risks and benefits, and must expressly consent to one of those options. However, many patients refrain from the option that their physician believes to be best, and many physicians worry that their patients make irrational healthcare decisions, hindering their ability to provide efficient healthcare for their patients. Some philosophers have proposed a solution to this problem: they advocate that physicians nudge their patients to steer them toward their physician's preferred option. A nudge is any influence designed to predictably alter a person's behavior without limiting his or her options or giving him or her reasons to act. Proponents of nudging contend that nudges are consistent with obtaining informed consent. In this article, the author argues that nudging is incompatible with genuine informed consent, as it violates a physician's obligation to tell his or her patients the truth, the whole truth, and nothing but the truth during adequate disclosure.
Luba R, Earleywine M, Farmer S, Slavin M. Cannabis in end-of-life care: Examining attitudes and practices of palliative care providers. J Psychoactive Drugs 2018. [E-pub ahead of print]; DOI: https://doi.org/10.1080/02791072.2018.1462543.
Medical cannabis research has become quite extensive, with indications ranging from glaucoma to chemotherapy-induced nausea. Despite increased interest in cannabis' potential medical uses, research barriers, cannabis legislation, stigma, and lack of dissemination of data contribute to low adoption for some medical populations. Of interest, cannabis use appears low in palliative care settings, with few guidelines available to palliative care providers. This study sought to examine the attitudes, beliefs, and practices of palliative care providers regarding the use of cannabis for terminally ill patients. Palliative care providers (N = 426) completed a one-time online survey assessing these attitudes, beliefs, and practices. Results demonstrated that palliative care providers endorse cannabis for a wide range of palliative care symptoms, end-of-life care generally, and as an adjuvant medication. Nevertheless, the gap between these beliefs and actual recommendation or prescription appears vast. Many who support the use of cannabis in palliative care do not recommend it as a treatment.
Chen LT, Hsiao FH. The effects of the interventions on the DNR designation among cancer patients: A systematic review. Palliat Support Care 2018. [E-pub ahead of print]; DOI: https://doi.org/10.1017/S1478951518000196.
The aims of this systematic review were to examine the effects of the overall and the different types of the interventions on the do-not-resuscitate (DNR) designation and the time between DNR and death among cancer patients.
Data were searched from the databases of PubMed, CINAHL, EMbase, Medline, and Cochrane Library through November 2, 2017. Studies were eligible for inclusion if they were (1) randomized control trails, quasi-experimental study, and retrospective observational studies and (2) used outcome indicators of DNR designation rates. The Effective Public Health Practice Project tool was used to assess the overall quality of the included studies. Results demonstrated that 14 studies with a total of 7180 participants were included in this review. There were 78.6% (11 of 14) studies that indicated that the interventions could improve the DNR designation rates. Three types of DNR interventions were identified in this review: palliative care unit service, palliative consultation services, and patient–physician communication program. The significant increases of the time between DNR designation and death only occurred in a patient–physician communication program. The authors conclude that the palliative care unit service provided a continuing care model to reduce unnecessary utilization of healthcare service. The palliative consultation service is a new care model to meet the needs of cancer patients in a nonpalliative care unit. The share decision-making communication program and physician's compassion attitudes facilitate to make DNR decision early. The authors suggest that the individualized DNR program needs to be developed according to the needs of cancer patients.