Making End-Of-Life Wishes Known Is Rare; More Hospice Care Could Save Medicare Money

[HuckleB]

http://www.medicalnewstoday.com/articles/170855.php

More at:

http://news.yahoo.com/s/ap/20091111/ap_on_he_me/us_health_overhaul_hospice_care

"Lillian Landry always said she wasn't afraid to die. So when death came last week, the 99-year-old was lying peacefully in a hospice with no needles or tubes. Her final days saw her closest friend at her side and included occasional shots of her favorite whiskey, Canadian Mist.

Landry is an exception. Unlike most Americans, she made her end-of-life decisions years ago: no heroic measures to save her and even instructions on the bar where mourners should gather.

The health overhaul bill that narrowly passed the House on Saturday includes a provision to nudge more people to confront such choices: It would pay for end-of-life counseling for Medicare patients.

Supporters say counseling would give patients more control and free families from tortuous decisions. Critics have warned it could lead to government "death panels." What few on either side note is that counseling could lead more people to choose less intensive care when they're dying, and ultimately trim government-funded health bills.

..."

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Important stuff, IMO.

[sarge43]

1. Almost as important, an End-of-Life statement (in writing and witnessed)

can protect your survivors/family from a medical/legal/financial horror show.

[laughingliberal]

2. Hospice nurse for many years, here

I was so pissed about the 'death panels' crap which rose up around a provision allowing people to have a visit with their doctor to discuss these issues. The suffering of the patient and emotional anguish of family members when the patient is unable to speak for themselves and left no wishes with anyone is unbelievable. Families are reluctant to move away from aggressive treatment to comfort care as they fear they are 'giving up on Mom (or Dad).' Sometimes I could relieve that by pointing to the person wasting away in the hospital bed with tubes everywhere and no control of their own lives or bodies and say, "Let me ask you this. Would you want to be kept alive under these circumstances? Do you see this as a desirable goal for your last days?" I never found one person who thought they would want that for themselves. Then I could ask, "Then why would you assume your Mother (Father, brother, etc...) would want this?" That usually worked but having advanced directives in place would have saved a world of anxiety and heartache.

[DURHAM D]

3. Hospice Care would not save Medicare money.

Hospice bills medicare for end of life services.

It does not cost the patient any money but the billing by Hospice to Medicare is unbelievable. I know this first hand in fact I am thinking about filing a claim of fraud against Hospice.

[Warpy]

4. Hospice is typically home based

although there are a few inpatient units for pain control and other issues.

Hospice workers visit two or three times a week to assist with bathing and to assess how the patient is doing in terms of comfort.

Hospice care, even on an inpatient unit, is far cheaper than intensive care. The only invasive procedures are IV starts for medication administration, and not every patient needs those. Intensive care involves things like multiple invasive lines plus massive amounts of electronic equipment and constant monitoring.

Anyone who says the costs are equivalent is speaking from deep ignorance and needs to do some reading.

[DURHAM D]

11. Please see my response below.

Hospice climbed on the back of my dying mother and billed for services not provided.

I resent that you call me ignorant but it is typical of your know it all attitude.

[Warpy]

12. If you were victimized by a Medicare scammer, that's too bad

but stating that hospice is more expensive than death in an intensive care is an ignorant statement for the reasons I explained.

Also, learn the difference between being called something and having a statement called something. It's quite a large difference.

[DURHAM D]

14. We were all of us (taxpayers) victimized by Hospice.

My father was paying privately for everything that anyone could think of to make her comfortable.

The point is that everyone believes that Hospice is "free". It is not. It is just another business.

My father died about two and a half hours ago. It was earlier that we expected so I was not there as I was to fly in on Tuesday. He was in the same special needs unit that my mother died in and was cared for by the same nurses that cared for my mother. All of his care was paid for privately.

Two days ago the facility where he lives suggested that we call in Hospice. Being smarter now we asked them why - what did he need that was not being provided? They couldn't provide an answer and we decided not to waste taxpayer dollars.

[Warpy]

15. Now it's time to do some reading

and find out what two weeks (which probably would have stretched into a month or more on life support) would have cost.

Ten grand was cheap. You do have a right to see their documentation and since you're obviously upset about this, I suggest you do.

[Name removed]

16. Deleted message

Message removed by moderator. Click here to review the message board rules.

[laughingliberal]

19. If, indeed, it is found the hospice agency is kicking back to the facility

that is a clear violation of Medicare regulations and does bear looking into. Hospice nor Medicare pay for what they call 'custodial care.' Hospice does see patients who reside in assisted living facilities and nursing homes and, once involved, they provide support to the staff and families and, generally, direct the care needed to provide symptom relief. One reason facilities often suggest calling in a hospice agency has to do with their guidelines. Often the facility is licensed for a specific level of care and, near the end of life, the patient falls outside the level of care for which they are licensed. Most states will issue a waiver to allow the patient to remain in what is now their home if hospice is directing the care. This is all pretty technical but it is to avoid requiring a patient with a few days or weeks to live having to move to a new facility. I have no doubt Medicare will investigate and, if there is fraud involved, they will recoup the money and a hefty fine to boot.

[Warpy]

21. All excellent points

and sometimes the change is only administrative.

However, it still voids the original point that hospice is as expensive as heroics. The bill from hospice was ten grand. A bill for standard treatment in an intensive care unit would easily be ten times that much and quite probably more.

The savings to Medicare for choosing hospice are substantial.

[laughingliberal]

22. Oh, I agree

It has been shown every time it was ever studied that more use of hospice saves the system money. It may be that some patients at end of life would not have used as much in terms of resources as hospice cost but most do and the savings to the system, overall, are substantial.

It does sound as if there may have been something amiss with the agency the poster to whom I was responding was involved with. But that, in no way, diminishes my belief in hospice as being not only a savings but the best vehicle for providing a dignified and humane way to spend the last days of life.

I worked as an oncology nurse for 15 years and as a hospice nurse for 10. Oncology made great strides during the years I practiced but I never was comfortable with the way many oncologists handled the terminal stages. Certainly, there were exceptions but I saw far too many who seemed to gloss over the prognosis with terminal patients and continue to treat resulting in many patients spending their last days in the hospital for complications of treatment. I woke up one day and realized I could not change the fact that some would die despite my best efforts but I could change the manner in which they died.

[Warpy]

23. I worked oncology, too

and saw the same thing you did, doctors who were knights in shining armor battling the demon cancer and completely losing sight of the patient in whose body their battle was being fought. I ended up in CCU and found cardiologists to be a little more sanguine about patient prognosis.

My mother had hospice care and they were wonderful. I was required only for the last few weeks when she became completely bedridden. I shudder to think what would have happened to her had she been in a hospital and undergoing all the best care money could buy.

[laughingliberal]

24. "I shudder to think what would have happened to her had she been in a hospital and undergoing all

the best care money could buy."

Yes, sounds as if we've both seen enough of the best care money could buy. So glad your mother's experience with hospice was good. It was a very rewarding area in which to work.

[laughingliberal]

5. It depends on the terminal illness whether it saves money or not

Medicare did their original study on this in the early 80's. They overwhelmingly found it saved them money. And that was with much higher reimbursement than Hospice agencies get nowadays. They have conducted studies periodically and they always show savings to the system. Does that mean that every case saves money? No. Some may have cost less as the treatments for the disease process would be relatively inexpensive. But in cases of end stage heart disease and cancer, it saves a fortune over terminal patients who can spend weeks in an ICU or on chemotherapy agents which can run hundreds of thousands of dollars in a couple of months.

The reimbursement schedules are set by Medicare and vary geographically. Hospice is paid a per diem rate-a set amount of money per day the patient is on service. Out of the money they receive they are required to provide all services and purchase all medication related to the terminal illness. They also must rent/purchase all equipment needed to care for the patient. It is, at it's core, a managed care model. Just as agencies, medical equipment companies, doctors, etc...are contracted with certain HMO's and receive X amount of dollars per patient the insurer has on it's roles under what is called capitated rates. Once a particular patient needs those services there is no extra money for the service. It is similar to this. Certainly, they come out ahead on some patients. They barely break even on others. And others, they lose money. The reimbursement rate for the area for which I practiced came out to around $3000 per month. I once had a patient whose pain was so out of control (bone cancer with a pathological fracture of the pelvis) that she was on Fentanyl 250 mcg per hour IV. the cost, just of that drug, to our agency was $12,000. We were the only agency in the area willing to take her. I also had some patients whose need was more along the lines of social workers (which Hospice provides) and nursing support for care givers. The costs were mostly limited to the portion of the staff salaries used by that patient. I have had patients who had a fall at home and fractured a hip due to their disease process and our agency picked up the bill for the hip surgery. In our area there were no inpatient hospice agencies. If a patient's care began to exceed what the family could handle with our support, we often had to arrange placement in a local hospital or convalescent facility. We were responsible for paying for that expense, also. Medicare did pay us more for the days the patient was inpatient but the rate was not much more than the bed cost us, meaning we operated at a loss once we paid for medications and our staff which continued to follow them and direct their care.

Lower cost patients' and their families often looked at the statements from Medicare showing the payments the agency received and wondered why so high. They were unaware of the way the system worked. Medicare sets the rate and the agency works within that to provide what is needed. For most patients the last 6-12 months cost as much or more than all their medical care up to that point. Medicare does not have a hospice benefit because they care about our suffering at the end of our lives. They have the hospice benefit because it saves them money. Regardless, it is a benefit to most patients to spend their last days free of suffering and able to be with family. Is that true of every case? No, nothing works for 100% of any population and it sounds as if your experience was not positive but it does not negate the cost savings and comfort derived since the hospice benefit was established in the United States in 1986.

edited to correct grammar

[sarge43]

6. As opposed to hospitals which have never over bill Medicare.

Just in case :sarcasm:

[DURHAM D]

10. My mother died in a special needs (Alzheimer's) unit.

She had been there for two years. My father picked up the tab ($6,200 a month) as almost nothing was billable to medicare except the doctor's visit every week or two. My mother had not been in a hospital since 1965.

So my father paid $10,000 for her care during the last six weeks of her life. She did not have a feed tube, she did not take any medication (except a little for pain in the last 10 days), she did not need medical attention. A Hospice social worker talked to my Dad a couple of times to help with the transition. If a skilled nurse was assigned by Hospice to her case we are not aware of it and one of us was with her at all times during the last two weeks. The nurses and aids on the floor (who have become close to) were not aware of a Hospice presence.

Nevertheless almost a year after the fact we have received a long report from medicare that Hospice billed $13,000 for services. My brother called to talk with medicare and they reviewed the billing with him. Medicare had assumed that Hospice was the primary care giver. They were not even the secondary care giver. Hospice needs to give the money back to the medicare fund.

[laughingliberal]

18. Doesn't sound good. Is Medicare investigating for you?

At the reimbursement rate in our area that would indicate a patient on service 95 days. I know Medicare regs in our area required an assessment by an RN at least every 30 days. My agency policy required an RN to see every patient no less than every 14 days. Social work and spiritual care were on an as needed basis beyond their initial assessments. We did not pay the bill for 'custodial care' which was, according to Medicare rules, the patient's home. I had quite a few patients who lived in a facility for Alzheimer's patients and I saw them every 1-2 weeks. An LPN who worked with me would see them on weeks I did not. I know I never made any visits without communicating with the med techs and resident care coordinator about each patient before leaving the premises. Same for the rest of our staff. We also had to leave copies of our paper work on the patient's facility chart. I know each state has a number to call for complaints regarding home health and/or hospice agencies. It sounds as if your brother has accessed that. I hope they get to the bottom of it for you.

[pansypoo53219]

7. my great-aunt is probably too incompetent now.

but she's 98 and has breast cancer and a bad ticker. and not taking her pills. suicide by demetia?

[mopinko]

8. dementia is part of death.

it isn't just forgetting where you left your glasses. it is forgetting how to swallow and how to breathe. taking pills is hard to do when it starts. but after a while taking pills is the least of it.

[Chemisse]

9. What a strange way to look at it

Forgetting how to swallow or breathe? Is this the same as slipping into a coma? Or is it brain death? Although I suppose dementia is partial brain death.

I am not being snide; I am curious about it.

[laughingliberal]

17. Here's an article on it

Development of problems with coordination of swallowing and breathing:

Typically, the person with dementing illness, as the disease progresses and the brain becomes more and more damaged, becomes not only cognitively impaired, but also progressively physically impaired. Swallowing becomes increasingly difficult. We have all had, I am certain, the occasional experience of drinking a liquid and inhaling at the same time, causing one to cough and choke. You aspirated fluids into your trachea (windpipe) and lungs when this happened. This situation is exactly what happens with many people with increasing brain damage when the brain no longer is capable of coordinating swallowing and breathing. The danger of aspiration of food or fluids into the lungs is that there is a tremendous potential for developing an aspiration pneumonia, due to inappropriate substances ending up in the lungs providing a medium in which bacteria can grow and prosper.

http://pages.prodigy.net/bjbservices/eol.htm

[Chemisse]

20. Thank you - that makes a lot of sense now - nt

[LeftishBrit]

13. Important to make your wishes known...

I know a number of people who have 'living wills' to prevent themselves being kept alive on machines when quality of life has become very poor.

Some people want to live no matter what; but many do not.