Research Shows Patients May Live Longer with Hospice and Palliative Care

[Jackie07]

Be aware of the patient's condition before putting him/her in hospice care.

My late Mother-in-law was put in Hospice care 'twice'. First time she was experiencing confusion (possibly a mini stroke that resolved itself) and the whole family gathered by her bedside. But she 'woke up' and was later moved back to her regular room in the nursing home. Six months later, she was under hospice care again before she passed away in peace. We were told that under hospice care she would actually get more attention and care.

Earlier this year, my Father-in-law was experiencing confusion for several days and could not take in food or use the bathroom. My Sister-in-law was sure that he was going to 'leave us' and went back to her home (four hours away) to get stuff she needed for a funeral. My husband and I took over the care of Father-in-law and soon realized that he'd been suffering from UTI (which typically causes confusion in the elderly) after we had called the EMS. Father-in-law has since been driving and cooking normally at the age of 87.

[gdpawel]

Elderly nursing home residents receive relatively few cancer care services, according to a study published in the Journal of the National Cancer Institute. Few studies have examined cancer treatment and care among elderly patients residing in nursing homes. Yet, as the population ages, more people will move into nursing homes, many of whom will later be diagnosed with cancer. Cancer risk increases as people age.

Nursing home residents (including any cancer patients) are already supposed to be receiving 24/7 care. The hospice service is an additional $130 a day the home receives. Because Medicare does not collect detailed data about the medical treatments a hospice patient receives, there is very little information about what services are actually being provided.

Neglect is the silent killer in nursing homes. By some estimates, malnutrition, dehydration, bedsores and infection - caused by neglect - account for half of nursing home deaths and injuries.

An indication of negligent care for cancer patients at nursing homes involved a woman in Pennsylvania who was put on the chemotherapy drug Nexavar. Its side effects include decreased blood flow to the heart, heart attack and high blood pressure. The woman was supposed to get emergency care immediately if she started to exhibit any signs of the side effects.

The woman reported a dull heavy chest pain and a severe band-like pressure around her head. Her blood pressure (200/123) was far higher than normal. There was no evidence that a physician was contacted about the situation. Later, a physician said she would have sent the woman to a hospital emergency room immediately.

Instead of calling the physician or getting the woman to the emergency room, the nursing home nurse gave the woman her scheduled dose of painkiller. Two hours later, the woman was found face-down in a small puddle of blood.

The home was cited for violating regulations relating to quality of care, management, patient rights, records and more. The home had previously been cited for similar violations.

There would be a much higher level of care given to residents if adequate staffing were provided. But, "for-profit" nursing homes, the desire for profit margins translates into less staffing at nursing homes, less training for the staff that they do have, less food (or a lower quality of food) for the residents, and less management and oversight.

A conflict arises between saving dollars and providing good care. Administrators benefit from the amount of profit generated by the nursing home they manage, usually paid annual bonuses based on bed-count. They must choose between increasing the profit margins of their individual facilities or supplying more support staff for the care of residents.

Even nursing home abuse may occur because of the desire for profit. Caregivers who work in nursing homes are often stretched beyond their ability. They try to do the best job that they can, but the lack of additional support restricts what they can do to help residents.

The for-profits are taking over hospices the same way they have taken over nursing homes. The Kaiser Network noted that hospice care was designed to be delivered mainly by not-for-profit groups with affiliations to religious and community groups, but the June 2008 MedPAC report found that since 2000 mostly for-profit companies and hospices have been providing such care.

ManorCare Health Services operates hospice under their for-profit nursing homes as Heartland Hospice Care. On top of receiving an additional $130 a day for hospice service, above the daily payment they receive providing nursing home care, they take donations to their Heartland Hospice Fund.

For-profit hospices, like for-profit nursing homes are run by corporations the are coldly efficient, according to a leading palliative care specialist. If there is a way to play the system to make a higher profit, they will. As I've said before, nursing home residents are already receiving 24/7 care. The hospice service is an additional $130 a day the home receives.

In their quest for Medicare dollars, for-profit hospices don’t provide all the care that they should in order to fulfill the hospice mission of maximizing patients’ quality of life.

In fact, a 2004 Medical Care study of 2,080 patients enrolled in 422 hospices across the country found that terminally ill patients who receive end-of-life care from for-profit hospice providers receive a full range of services only half the time compared with patients treated by nonprofit hospice organizations.

That’s because for-profit hospices like to keep costs low by skimping on services, particularly so-called “non-core” services like medications and personal care. For example, families of patients receiving care from a for-profit hospice received counseling services, including bereavement counseling, only (45% as often) as those in a nonprofit hospice.

When researchers controlled for differences across patients, sicknesses, and conditions, those at for-profit hospices were only half as likely to get the same support provided at nonprofit hospices. A 2005 follow-up study confirmed that for-profit patients receive a narrower range of services than nonprofit patients.

But it’s not just “non-core” services that for-profit hospices are skimping on. For-profit hospices are only half as likely as nonprofits to provide palliative radiotherapy (RPT), a radiation therapy that has been shown to effectively reduce pain and other symptoms related to tumor growth.

The dearth of for-profit RPT probably has a lot to do with the fact that for-profit hospices take on a smaller share of patients with cancer than do nonprofits—in part because it costs a lot to care for cancer. In addition, it’s much easier to predict how soon cancer patients will die. They rarely stay in a hospice for more than six months.

Indeed, for-profit hospices tend to “cream-skim” patients, both by taking on fewer cancer patients and having a greater share of patients who require a relatively long stay (In this regard, MedPAC’s fears are warranted).

Worse still, according to research from the University of California, Irvine, patients who stay longer at for-profit hospices receive less high-skilled nursing care—such as tracheotomy care, wound care, and suctioning or feeding tubes—because skimping on these services keeps costs down. In sum, research shows that patients stay longer at for-profit hospices, yet receive less personal care, symptoms management and spiritual support during their stay.

This is a pretty good way to make money, and indeed, the largest for-profit hospices are doing very well: a 2005 study in the Journal of Palliative Medicine found that large hospices owned by publicly traded companies generate profit margins nine times higher than those of large nonprofits and three times higher than privately owned for-profit hospices of similar size. In other words the "corporatization" of nursing homes seems to be a major part of the problem.