Is end-of-life care threatened by today’s healthcare environment? – Part 2

FOUNDATION 1: Patient-Centered, Whole-Person Care

The hallmark of compassionate end-of-life care is to treat each patient as an individual, listen to his or her needs, and recognize that dying is not just a physical process but an experience of the whole person—and the family as well. This awareness of the needs of the whole person led to the well- known concept of “total pain,” which is one of Dr. Saunders’ greatest contributions to the hospice and palliative care body of knowledge. Equally important is caring for a patient throughout the entire end of life and not abandoning the patient as death approaches.

In keeping with Dr. Saunders’ vision, the 2015 Institute of Medicine Report, Dying in America, features a list of “Proposed Core Components of Quality End-of-Life Care,” which the Institute suggests should apply to care for all individuals as they near the end of life. The list includes management of pain and other physical symptoms as well as attention to the patient’s emotional, social, spiritual, and religious needs.¹³

But in sharp contrast to these components of quality care, “some hospices are making determinations of hospice coverage based solely on cost and reimbursement as opposed to being based on patient-centered need, preferences, and goals for those approaching the end of life,” according to regulators for the Centers for Medicare and Medicaid Services (CMS).¹⁴

In various studies, for-profit hospices have been found to provide a narrower range of services to dying patients than not-for-profits,¹⁵ including:

• Fewer visits from nurses during the last few days of life,¹⁶
• Less continuous nursing and inpatient care,¹⁷ and
• Fewer options for pain relief, such as palliative radiotherapy.¹⁸

In addition, for-profit hospices are more likely than not-for- profits to discharge patients before death (22 percent vs 14 percent), which, according to analysts, indicates a prioritization on profitability over quality patient care.¹⁹

The study results reveal the incompatibility of a hospice model based on profit maximization with the compassionate end-of- life care envisioned by Dr. Saunders. In fact, one investment analyst bemoaned the fact that profit margins in hospice are not yet as high as they could be because not-for-profit providers still “aim to fulfill their missions rather than turn a profit.”²⁰

Yet according to Dr. Ira Byock in his book The Best Care Possible, end-of-life care that is patient-centered (rather than profit-centered for wealthy investors) actually can help lower healthcare costs. Byock quotes a Dartmouth Atlas study that “estimated that Medicare could reduce hospital costs by 28–43 percent by adopting the patient-centered, proactive approaches of the most efficient systems.”²¹ These cost savings are possible because patient-centered care often leads to fewer unnecessary tests and less unwanted treatment.

SUMMARY: “When patients and family members have control over the end-of-life experience and define quality and what is important to them—we are fulfilling the heart of hospice care and helping patients fully live until they die,” said Kent Anderson, CEO of Ohio’s Hospice.

“Not-for-profit organizations are dedicated to fulfilling the wishes of the patient—not just providing the basic care covered by Medicare, Medicaid, or other insurance benefits,” Anderson explained.

Preserving the concept of whole-person, patient-centered care to the entire healthcare system will reduce costs and ensure that patients’ needs are met at the end of life.