Comfort measures only vs. hospice care: Initiative seeks right setting for patients at end-of-life 

Healthcare providers are taught to “first, do no harm.” This ethos extends to providers doing everything they can within their scope of practice to heal and improve quality of life. 

But what happens when patients stop responding to curative-intent treatment? End-of-life care can be a difficult topic for the healthcare team as well as patients and their loved ones. Yale New Haven Health (YNHHS) has taken steps to ensure that patient-centered care is provided in the most appropriate setting for patients eligible for hospice care.

“Too many patients die in our hospitals with orders for comfort measures only when they would have been better served with a referral to hospice care,” said Scott Sussman, MD, executive director, Office of the Chief Medical Officer, Yale New Haven Hospital, who is leading the YNHHS initiative for greater awareness and optimization of hospice care. “We must do better for our patients.”

Dr. Sussman noted that dying patients qualify for routine hospice, but often don’t qualify for inpatient hospice per Medicare regulations, and that 99 percent of hospice care is outside the hospital setting. 

“It’s hospice care – not acute-care hospitalizations – that can provide the best care and experience for patients at end-of-life,” he said.

Some people may not realize there is a difference between palliative care and hospice. Palliative care is appropriate at any age and any stage of serious illness and focuses on managing symptoms and improving quality of life. Hospice is intended for patients with a limited life expectancy who no longer seek curative treatment. Palliative care doesn’t have a timeline, whereas hospice care is usually for those with a life expectancy of six months or less.

The patient’s wishes are important in determining where they receive end-of-life care. Seventy percent of patients want to die somewhere other than the hospital; a study published in the New England Journal of Medicine (December 12, 2019) shows that over 50 percent of patients would choose to die at home. End-of-life care is often best outside the hospital; and hospice manages the patient’s symptoms, pain and mental well-being while supporting the family. Besides the home, hospice is offered in assisted living and skilled nursing facilities and hospice centers like Connecticut Hospice. 

For patients admitted to YNHHS who qualify for inpatient hospice and are unable to transfer to an alternative care location, contracted vendors provide hospice in the hospital. However, these patients accounted for only 29 percent of anticipated inpatient deaths last fiscal year. The other 71 percent of patients died with comfort measures only, without hospice. When patients die without hospice, families are not supported by the 12-month bereavement benefit after their loved one dies. 

YNHHS’ renewed focus on appropriate discharge to hospice will improve care by connecting end-of-life patients and their families with hospice. To measure the impact of the hospice optimization initiative, YNHHS seeks to decrease the number of patients who die in the hospital as comfort measures only without hospice services by 20 percent by Dec. 31, 2023.

The initiative is designed to streamline processes for connecting appropriate patients with hospice care by:

• Having every comfort measures-only patient evaluated for hospice
• Better positioning Care Management to work with providers and patients in transitioning to hospice care (including home hospice when feasible and desired by family) 
• Improving processes with hospital teams and hospice vendors that provide inpatient hospice care.

“Physicians may be reluctant to refer a patient to hospice because we are hardwired to find solutions for our patients’ medical conditions. Like many of our patients, we too hope that they will rebound,” Dr. Sussman said. “However, clinicians need to consider the right care in the right place at the right time, and remember that end-of-life care is often best outside the hospital.”

For more information about the hospice care optimization resources and process, refer to the End-of-Life Education intranet site or contact [email protected]