Hospice and functional decline
January 29, 2013 3 Comments
An interesting new paper in the Journal of the American Geriatrics Society (JAGS) on different patterns of functional decline (ability to walk, eat, cognition) among persons who were in hospice care and ultimately died. The most important point of the paper is that there is great heterogeneity in ability to function, even on the last day of life.
In an inverse probability–weighted sample of individuals who had a PPS score recorded in the last day of life (n = 1,959, 22.6%), 35.9% had a PPS score of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. [my note: PPS in this context is a standard functional status measure often used in hospice and palliative care settings; 10 is quite poor, 90 is very good]
Two points on hospice policy here, both related to MEDPACs great interest in (shortening) long stay hospice users. First, over one-third of patients in this sample had reasonable functioning on the day they died. This shows the difficulty of predicting death with any precision, even among the subset of patients enrolled in hospice (all patients in this study died, so this is not an issue of discharging alive from hospice). Second, table 2 from this study demonstrates the current reality of hospice as not simply being used to treat Cancer; a broader set of conditions including dementia and debility(or frailty) are also included. Such conditions tend to have a less clear disease course than does Cancer. Both the difficulty of predicting death, and the spread of hospice into non Cancer diagnoses (which has been a stated goal of Medicare hospice policy), have likely contributed to the increase in relatively long hospice stays that have drawn so much policy attention. More work to demonstrate the link between functional status and length of hospice use/patterns is likely to be an important part of any Medicare hospice payment reform.
Pamela Harris, Esther Wong, Sue Farrington et al. Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect. Journal of the American Geriatrics Society 2013 online first.