Prior work has shown that symptoms leading to restrictions in daily activities are common at the end of life. Hospice is a Medicare benefit designed to alleviate distressing symptoms in the last 6 months of life. The effect of hospice on the burden of such symptoms is uncertain.
Methods
From an ongoing cohort study of 754 community-dwelling older persons, aged ≥70 years, we evaluated 241 participants who were admitted to hospice from March 1998 to December 2013. A set of 15 physical and psychological symptoms leading to restricted activity (ie, cut down on usual activities or spend at least half the day in bed) were ascertained during monthly telephone interviews in the year before and 3 months after hospice admission.
Results
The prevalence and mean number of restricting symptoms increased progressively until about 2 months before hospice admission, before increasing precipitously to a peak around the time of hospice admission. After the start of hospice, both the prevalence and the mean number of restricting symptoms dropped markedly. For several symptoms deemed most amenable to hospice treatment, including depression and anxiety, the prevalence dropped to levels comparable to or lower than those observed 12 months before the start of hospice. The trends observed in symptom prevalence and mean number of symptoms before and after hospice did not differ appreciably according to hospice admission diagnosis or sex. The median duration of hospice (before death) was only 15 days.
Conclusion
The burden of restricting symptoms increases progressively several months before the start of hospice, peaks around the time of hospice admission, and decreases substantially after the start of hospice. These results, coupled with the short duration of hospice, suggest that earlier referral to hospice may help to alleviate the burden of distressing symptoms at the end of life.
Toward the end of their lives, many patients point to the alleviation of distressing symptoms as their most pressing need. A recent Institute of Medicine report, however, found that symptom management at the end of life is often inadequate.3 Despite calls to address this inadequacy, the problem has gotten worse in the last decade. The prevalence of the most distressing end-of-life symptoms increased between 1998 and 2010 and remains high today. Furthermore, symptom burden steadily increases during the last year of life.
One of the most common approaches to ameliorating distressing symptoms is palliative care. Prior studies have shown that palliative care can significantly improve quality of life and even increase survival rates. At the end of life, hospice, a specific type of palliative care, is often considered. Hospice use has grown substantially in the past decade. However, the median length of stay in hospice has remained very short, at approximately 2.5 weeks. Because a primary objective of hospice is to provide symptom relief in the last 6 months of life,16 this short duration raises concerns about whether hospice is being properly utilized.
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-Shayan Cheraghlou, BA, Evelyne A. Gahbauer, MD, MPH, Linda Leo-Summers, MPH, Hans F. Stabenau, PhD, Sarwat I. Chaudhry, MD, Thomas M. Gill, MD
This article originally appeared in the July 2016 issue of The American Journal of Medicine.
