Monday, September 17, 2018

End of Life care - the glass is half full

Ethicist and Oncologist Ezekiel Emanuel wrote an editorial in the July 17, 2018 edition of JAMA which is quoted below. He is commenting about this article: Site of Death, Place of Care, and Health Care Transitions Among US Medicare Beneficiaries, 2000-2015. (JAMA. 2018;320(3):264-271. doi:10.1001/jama.2018.8981)
Emanuel points out continuing how medical end-of-life care is continuing to evolve in the USA. More of us are dying outside the acute care hospital, but still too many of us are in the ICU or receiving chemotherapy in our last days. Hospice utilization continues to dramatically improve. 
Almost everyone has a story about end-of-life care gone bad. The available data reveal many reasons for frustration with how care for dying patients is currently delivered. But rather than see the glass as half empty, the historical perspective offered by Teno and colleagues in this issue of JAMAis a reminder of how far the US health care system has come on end-of-life care. This study suggests 4 important messages about the status of end-of-life care.
Improvements in End-of-Life Care
First, the glass really is half full. Regarding site of death, about half of all patients died in the hospital during the 1980s.2 During the 1990s, the rate declined such that by 2000 only 32.6% of Medicare beneficiaries died in the hospital. The decline continued so that, as Teno et al1 report, by 2015 19.8% of deaths among Medicare beneficiaries occurred in the hospital. Concomitantly, hospice use has increased. In 1980, hospice use was almost zero. Hospice use was at 21.6% by 2000 and by 2015 more than 50% of Medicare decedents received hospice care.
Simultaneously, it is important to acknowledge that the glass is not full. Almost two-thirds of all dying Medicare patients are hospitalized during the last 90 days of life—a proportion that is higher than in 2000. Even more discouraging, admissions to the intensive care unit (ICU) during the last 30 days of life increased starting in 2000 until 2015. Today, nearly one-third of patients receive care in the ICU during the last 30 days of life. Similarly, among patients with cancer, about 75% are hospitalized during the last 6 months of life, more than 40% are admitted to the ICU, and nearly 40% are still receiving chemotherapy.3 Even during the last 30 days of life, when death for a patient with cancer is not just predictable but inexorable, more than 50% are hospitalized, more than 25% are admitted to the ICU, and 10% receive chemotherapy.
Thus, even though significant improvements have been made in end-of-life care over the last 35 years, many problems still need attention and progress.

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