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Fewer people dying in hospitals, stressful end-of-life transitions reduced

Study finds place of death shifted as Affordable Care Act discussed, enacted
Final wishes
A new study indicates people are increasingly able to die according to their wishes, with fewer taking their last breaths in hospitals. (Getty Images)

Fewer people are taking their last breaths in the hospital and are instead dying in their homes, assisted living facilities and other community settings, according to a study published in JAMA and presented Monday at the AcademyHealth 2018 Annual Research Meeting in Seattle.

Joan M. Teno, M.D., M.S.
Joan M. Teno, M.D., M.S.

The finding indicates people are increasingly able to die according to their wishes, said the study’s lead author Joan M. Teno, M.D., M.S., professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine.

“This tells me we’re on the right path. We’re listening to people who tell us they don’t want to die in a hospital setting as we’re expanding access to hospice and palliative care teams,” said Teno, who is also a senior scholar at the OHSU Center for Ethics in Health Care.

Teno and colleagues at OHSU and Brown University found people dying in hospitals decreased from almost 33 percent in 2000 to nearly 20 percent in 2015. In addition, stays in hospital intensive care units during the last month of life have stabilized at 29 percent of patients since 2009, and incidents of patients being moved to a different health care facility during the last three days of life decreased from 14 percent of patients in 2009 to less than 11 percent in 2015.

This study is an update to a 2013 JAMA paper by Teno and colleagues, which found at that time more people were dying shortly after staying in intensive care, being repeatedly hospitalized, and experiencing transitions in care that are burdensome to dying persons and their families.

The previous study examined Medicare patient data between 2000 and 2009, while the new paper has an expanded dataset through 2015. In between the two studies, the Patient Protection and Affordable Care Act, also known as Obamacare, was debated in 2009 and enacted in 2010.

The Affordable Care Act transitioned the U.S. from paying for services such as hospitalizations to paying for the quality of health care outcomes. For example, hospitals are now fined when their patients are readmitted within 30 days of being released and Accountable Care Organizations provide incentives based on the quality of health care. Teno said this transition led hospitals “to think carefully” about post-hospital care and encouraged the use of palliative care, which focuses on improving the quality of life for patients with serious illness.

A decrease in burdensome health care transitions is particularly important, Teno said, as being transferred to a hospital can be especially stressful and discomforting for patients nearing the end of their lives.

“Anytime you change health care settings, there’s a whole new set of providers who need to get to know you,” Teno said. “Imagine you’re in the last days of your life and the patient or family has to explain your needs to a whole new group of caregivers.”

There has been growth in community-based palliative care teams since the enactment of the Affordable Care Act. Teno is now working with colleagues to study the impact those teams have on the quality of care.

This research was supported by the Robert Wood Johnson Foundation and the National Institute on Aging (grant P01AG027296).

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