Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect?

Harris, Pamela; Wong, Esther; Farrington, Sue; Craig, Teresa; Harrold, Joan; Oldanie, Betty; Teno, Joan M.; Casarett, David

doi:10.1111/jgs.12144

Cited by 20 publications

(21 citation statements)

References 19 publications

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“…Specific diseases are associated with certain patterns of decline, 11-13 but we find that diseases are not associated with particular spending trajectories. Instead, it is the number of conditions that appear to be most relevant to end-of-life spending.…”

Section: Discussioncontrasting

confidence: 68%

“…Prior work has suggested that certain diseases are associated with a pattern of decline that may be reflected in spending. 11-13 More detailed information about the course of spending near the end-of-life may provide important insights about the drivers of end-of-life spending and shed light on potential strategies to mitigate the costs while preserving high quality care for people who are dying. 14 …”

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confidence: 99%

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Identification Of Four Unique Spending Patterns Among Older Adults In The Last Year Of Life Challenges Standard Assumptions

et al. 2016

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The underlying assumption that healthcare spending skyrockets at the end-of-life may suggest that policymakers should target the last few months of life to control costs. However, spending patterns leading up to death have not been fully examined. We applied a new methodology to administrative claims data for older Medicare beneficiaries who died in 2012 to characterize trajectories of healthcare spending in the last year of life. After adjustment, we identified four unique spending trajectories among decedents: 48.7 percent had High Persistent spending, 29.0 percent had Moderate Persistent spending, 10.2 percent had Progressive spending, and only 12.1 percent had Late Rise spending. High spending throughout the full year before death (approximately half of all decedents) was associated with having multiple chronic conditions but not any specific diseases. These findings suggest that spending at the end-of-life is a marker of general spending patterns often set in motion long before death.

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Section: Discussioncontrasting

confidence: 68%

mentioning

confidence: 99%

Identification Of Four Unique Spending Patterns Among Older Adults In The Last Year Of Life Challenges Standard Assumptions

et al. 2016

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“…1,2,13,14,24 These prospectively collected data mirror some longer prospective 2,24 and retrospective 1,25 trajectory studies for cancer, organ failure, 2,13,14 and frailty/dementia. 2,12,14 Data show there are rapid periods of decline in the last 14 -22 days of life for all diagnostic cohorts, with the average AKPS score dropping by 15 -26 points.…”

Section: Significance Of the Findingsmentioning

confidence: 99%

The trajectory of functional decline over the last 4 months of life in a palliative care population: A prospective, consecutive cohort study

et al. 2019

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Background: Understanding current patterns of functional decline will inform patient care and has health service and resource implications. Aim: This prospective consecutive cohort study aims to map the shape of functional decline trajectories at the end of life by diagnosis. Design: Changes in functional status were measured using the Australia-modified Karnofsky Performance Status Scale. Segmented regression was used to identify time points prior to death associated with significant changes in the slope of functional decline for each diagnostic cohort. Sensitivity analyses explored the impact of severe symptoms and late referrals, age and sex. Setting/participants: In all, 115 specialist palliative care services submit prospectively collected patient data to the national Palliative Care Outcomes Collaboration across Australia. Data on 55,954 patients who died in the care of these services between 1 January 2013 and 31 December 2015 were included. Results: Two simplified functional decline trajectories were identified in the last 4 months of life. Trajectory 1 has an almost uniform slow decline until the last 14 days of life when function declines more rapidly. Trajectory 2 has a flatter more stable trajectory with greater functional impairment at 120 days before death, followed by a more rapid decline in the last 2 weeks of life. The most rapid rate of decline occurs in the last 2 weeks of life for all cohorts. Conclusions: Two simplified trajectories of functional decline in the last 4 months of life were identified for five patient cohorts. Both trajectories present opportunities to plan for responsive healthcare that will support patients and families.

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“…16 Consequently, many older persons do not receive hospice or palliative care near the end of life, 17,18 which can place a high burden on caregivers 19 and result in suffering. 20 Although functional decline among patients in hospice has been previously evaluated, 21,22 the course of disability before hospice has not been well characterized. Several prior studies [23][24][25][26] have evaluated the prevalence and time course (or trajectory) of disability at the end of life, but have not focused on the functional antecedents to hospice admission.…”

Section: Introductionmentioning

confidence: 99%

Functional Trajectories in the Year Before Hospice

Stabenau

Morrison

Gahbauer

et al. 2015

The Annals of Family Medicine

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PURPOSE We undertook a study to identify distinct functional trajectories in the year before hospice, to determine how patients with these trajectories differ according to demographic characteristics and hospice diagnosis, and to evaluate the association between these trajectories and subsequent outcomes.METHODS From an ongoing cohort study of 754 community-living persons aged 70 years or older, we evaluated data on 213 persons who were subsequently enrolled in hospice from March 1998 to December 2011. Disability in 13 basic, instrumental, and mobility activities was assessed during monthly telephone interviews through June 2012. RESULTSIn the year before hospice, we identified 5 clinically distinct functional trajectories, representing worsening cumulative burden of disability: late decline (10.8%), accelerated (10.8%), moderate (21.1%), progressively severe (24.9%), and persistently severe (32.4%). Participants with a cancer diagnosis (34.7%) had the most favorable functional trajectories (ie, lowest burden of disability), whereas those with neurodegenerative disease (21.1%) had the worst. Median survival in hospice was only 14 days and did not differ significantly by functional trajectory. Compared with participants in the persistently severe trajectory, those in the moderate trajectory had the highest likelihood of surviving and being independent in at least 1 activity in the month after hospice admission (adjusted odds ratio = 5.5; 95% CI, 1.9-35.9). CONCLUSIONSThe course of disability in the year before hospice differs greatly among older persons but is particularly poor among those with neurodegenerative disease. Late admission to hospice (as shown by the short survival), coupled with high levels of severe disability before hospice, highlight potential unmet palliative care needs for many older persons at the end of life. INTRODUCTIONO lder persons with persistent levels of severe disability have high mortality and substantial care needs.1,2 One option for addressing these needs is palliative care, a specialized medical and interdisciplinary care approach that aims to alleviate stress, pain, and other distressing symptoms among those with serious illness, independent of prognosis or treatment being pursued, with the goal of optimizing quality of life for both patients and families.3 Hospice care, a similar approach, is a second option. In the United States, hospice is largely defined by the Medicare Hospice Benefit, which restricts services to persons who have an expected survival of 6 months or less. Because hospice also limits the pursuit of curative and most life-prolonging therapies, it is often considered only for patients who have end-stage, terminal conditions, or when death is imminent. [4][5][6][7][8][9][10][11][12][13][14][15] Palliative care is often confused with hospice and can be difficult to access. 16 Consequently, many older persons do not receive hospice or palliative care near the end of life, 17,18 which can place a high burden on caregivers 19 and result in suffering. 20Alt...

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Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect?

Cited by 20 publications

References 19 publications

Identification Of Four Unique Spending Patterns Among Older Adults In The Last Year Of Life Challenges Standard Assumptions

Identification Of Four Unique Spending Patterns Among Older Adults In The Last Year Of Life Challenges Standard Assumptions

The trajectory of functional decline over the last 4 months of life in a palliative care population: A prospective, consecutive cohort study

Functional Trajectories in the Year Before Hospice

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