Patient preferences aren't the only reason for underuse of hospice services. Medicare typically pays hospices a per diem rate, which has also been cited as a factor. A study published in Health Affairs found that 3 out of 4 hospices surveyed in 2008 and 2009 reported policies that would exclude complex patients who need transfusions, palliative chemotherapy, tube feeding and other costly services.
The Care Choices Model will allow patients to enter hospice before they fully come to terms with their terminal prognosis, experts say. For seriously ill patients, the choice of when to stop treatment can be murky. How patients come to accept dying is profoundly personal. A prognosis may be overshadowed by religious beliefs, emotional turmoil or how well someone feels, and family members' views and desires, regardless of the patient's deteriorating health.
Recent studies highlight how widely patients' perceptions of their health can deviate from the medical facts. “Sometimes those can be really, really far apart,” said Rafael Romo, a nurse and quality scholar fellow at the San Francisco Veterans Affairs Medical Center.
He cited a 2011 randomized controlled trial of palliative care combined with cancer treatment versus only cancer treatment. Half the patients reported being “relatively healthy” at the start and only 13% reported a terminal illness, despite having metastatic nonsmall-cell lung cancer, which has an estimated prognosis of one year from when patients are diagnosed.
A separate analysis of those patients found two-thirds of those same patients reported their goal for care was a cure. One-third reported their cancer could be cured, despite a diagnosis with the likelihood they would not survive more than a year.
Romo said the Medicare Care Choices Model will allow patients “time to adjust” with support from hospice providers, who include social workers, clergy and bereavement counselors. Even for patients who don't believe they will die, additional time allows for repeated conversations to help patients identify their goals for medical intervention and more clearly understand their condition. “They'll be able to see their health in a more realistic way,” he said.
Research published this month in JAMA Oncology found chemotherapy did not improve the quality of life for patients in their final days. Indeed, for those patients least debilitated by cancer, chemotherapy worsened their quality of life.
The new model will give patients and their families more time to build trust with the social workers, nurses and doctors on the hospice team, Banner's Oppenheim said. That trust can help with acceptance of the dying process and improve the quality of the patient's remaining days, he added.
“Hospice really has a lot more to offer patients and families” than can be experienced in two weeks, which is the median time patients spend in hospice, he said. “It's a rush job at the end.”