Letter: Response to Feder et al.,Use of Hospice and End-of-Life Care Quality Among Medical Centers with High Versus Lower Specialist Palliative Care Reach Among People with Heart Failure: An Observational Study

Dear Editor:

A recent letter ¹ from Dr. Martin provided commentary on our publication on the use of hospice and end-of-life care quality among Department of Veterans Affairs (VA) medical centers with varying rates of specialist palliative care among people with heart failure. We wish to respond to several of these comments.

Dr. Martin states that due to provisions within the Medicare Hospice Benefit, “hospice care cannot be provided in a VA medical facility.” ¹ However, this statement pertains to the Medicare-paid hospice care. The VA provides inpatient hospice care for all enrolled Veterans, the majority of whom are dually enrolled, ² within most VA medical centers nationally. ³ The Veterans’ Health Care Eligibility Reform Act of 1999 mandates that the VA offer to provide hospice and palliative care services to eligible enrolled Veterans who need these services or purchase them from the community. ⁴ Thus, Veterans have the option to receive VA-provided or paid hospice services, where inpatient hospice services are delivered on acute medical units, or to receive hospice/palliative care within designated hospice beds or in Community Living Centers. If beds are not available within the VA, Veterans in need of inpatient hospice care can have room and board covered at select contracted nursing homes where routine hospice benefits are often covered concurrently under Medicare.

We object to the assertion that Veterans face a barrier to hospice care and seek to distinguish hospice-level care, as the focus of our published work, from the Medicare Hospice Benefit. To refer to Dr. Martin’s example, a heart failure patient too unstable for transfer out of acute care settings in a VA medical center would indeed receive inpatient hospice services, though not the Medicare-specific hospice benefit, whether it be on a general hospital ward or on a specialized palliative unit in a VA medical center.

Rates of inpatient hospice within our study of people with advanced heart failure were very high. ⁵ Almost 50% of people with heart failure who died in a VA medical center received inpatient hospice services; this rate reached 65–68% for those who received specialist palliative care. While not the primary focus of our article, we believe our findings reflect high-quality end-of-life care. We acknowledge in our limitations that we did not capture hospice services outside of the VA inpatient setting. This limitation is the focus of our ongoing work.