Hospital Deaths a Poor Quality Metric for Patients With Cancer

Abstract

During the past 10 years, many organizations have implemented quality metrics for end-of-life care. One of the most important is inpatient hospital mortality, 1 which is typically reported as a mortality ratio, ie, observed vs expected deaths, and is used by many major organizations to rank hospitals 1,2 ; its use is supported by survey studies that have found that most patients express the desire to die at home. 1,3,4 However, it is not clear whether patients in these studies have understood the complexity of end of life at home.Patients with cancer and their caregivers may not be aware of the burden of care that would fall on them or the limited support delivered at home by hospices. 1 Patients with cancer who live alone will need to move in with a relative, or a relative will need to move in with them. Caregivers are usually the same age as the patient (mid-60s), 5 and the vast majority do not have any medical or nursing training. They will now be responsible for the following: administering multiple regular medications, making decisions about needed medications for different symptom problems, providing hygiene, helping the patient with elimination, assisting the patient with repositioning as he or she progressively becomes completely bedridden, and providing around-the-clock physical and emotional support. For the most part, they will be alone with the patient at the moment of death. There are side effects to a home death for patients and their loved ones. Failure to disclose those will result in less-reliable consent. Also, in some cultures, a home death is not seen favorably, and universally enforcing it could lead to culturally callous care.Patients enrolled in hospice care this year during the last week of life received a nursing visit on approximately 40% of the days (whether the visitors were registered nurses or nursing assistants was not specified), they received a visit from a social worker or counselor on approximately 9% of the days, and the vast majority of them never saw a physician during their last week of life. 4 This level of care may be enough for some patients with very stable chronic conditions. It also may be seriously deficient for patients with cancer unless they have minimal discomfort or are able to afford considerable family or private duty support.Patients with cancer frequently develop devastating physical and psychosocial symptoms before death. At the time of great profit margin (approximately 17% from 2017 through 2019), for-profit hospice organizations have provided very limited, and not increasing, care. 4 Perhaps for these reasons, care for patients with cancer decreased from more than 90% of the hospice patient population at the inception of the Medicare hospice benefit in 1983 to less than 26% in 2019. 4

A Critique of Recent Medical Research in JAMA on COVID-19

“…Further to the interesting perspective of Tang and Bruera (2020), the quality of life is important and essential for every individual, regardless of their health status.…”

Team-Based Hospice Referrals: A Potential Quality Metric for Lung Cancer in the Immunotherapy Era

“…15 Despite increasing awareness of research findings and guidelines advocating timeliness in EOL parameters, the trend may be worsening for thoracic oncology. [16][17][18][19][20] Hospice referral can be delayed by uncertainty in prognosis, a challenging assessment when multiple efficacious treatment options are available. [21][22][23] Along those lines, NSCLC has had a decade of breakthroughs in translational research allowing more treatment options than ever before.…”

Addressing inequitable access to hospice care

“…The increased number of deaths occurring in the community, compared with inpatient hospice services, has also shifted the burden of care for families. Pre-pandemic, this was already a recognised issue within specific healthcare systems (eg, USA) where hospice care at home is financially driven and support for caregivers is limited 11…”

“…Pre-pandemic, this was already a recognised issue within specific healthcare systems (eg, USA) where hospice care at home is financially driven and support for caregivers is limited. 11 …”