Live Discharge From Hospice: A Systematic Review

Serena Wu; Deborah L. Volker, PhD, RN, FAAN

Journal of Hospice and Palliative Nursing. 2019;21(6):482-488.

Abstract and Introduction

Abstract

Live discharges from hospice may occur because of patient choice or provider choice. However, when discharges occur before death, patients and families may feel abandoned and left to manage care needs previously provided by hospice. The purpose of this systematic review was to better understand the nature of live discharges, including frequency, patient characteristics, and hospice characteristics. Of 44 studies identified for review, 13 met inclusion criteria and were published between 2008 and 2018. Live discharge rates varied from 5% to 23%. Patients' prehospice characteristics varied widely based on diagnosis, comorbidities, gender, race, and ethnicity. Hospice characteristics indicated that the likelihood of a live discharge was increased for patients enrolled in for-profit hospices and in rural areas. Only 2 studies captured the patient/family perspective of the live discharge experience, finding that the loss of hospice support was fraught with difficulties. A need for further study of the live discharge experience and the practices of hospices with high live discharge rates was identified.

Introduction

The use of hospice services for end-of-life care continues to rise throughout the United States. Indeed, older adults who are Medicare beneficiaries constitute the largest group of hospice recipients, with 1.43 million enrollees in 2016.^[1] According to the National Hospice and Palliative Care Organization, 48% of all Medicare decedents were receiving hospice care at the time they died.^[1] Typically, such individuals are older (≥80 years of age) and white and have a cancer diagnosis, although cardiac/circulatory disease and dementia are the second and third most frequent diagnoses, respectively.

Although the rising use of hospice represents a "good news" scenario for quality end-of-life care, recent scrutiny of hospice care practices by the lay press has heightened both public and professional awareness of questionable practices by some hospices. For example, the Washington Post analyzed thousands of hospice records and concluded that, as compared with nonprofit hospices, for-profit hospices spent less on nursing per patient, were less likely to provide a nursing visit to a patient's home in the final days of life, were less likely to provide care for patients with symptoms difficult to control, and had more patients leave hospice care before death.^[2] Similarly, a study by Dolin et al^[3] revealed that hospices with the highest profits had the highest rate of discharging patients prior to death.

The issue of live discharge from hospice warrants special scrutiny because it can leave patients and families feeling abandoned and without resources for ongoing care needs.^[4] Live discharge, meaning a discharge from hospice prior to a patient's death, can occur because the patient has stabilized and no longer qualifies for hospice services or a patient chooses to pursue aggressive treatment or to transfer to a different hospice. However, Dolin et al^[3] have raised questions about live discharge decisions that may be for reasons other than the patient's best interests. As such, it is important to understand the practice and patterns of live discharges in order to generate recommendations for patient and family education and care, as well as health policy and reimbursement regulations. To this end, the purpose of this systematic literature review was to answer the following questions: What is the frequency of live discharges? What are the characteristics of patients who are discharged alive from hospice? What are the characteristics of hospices where live discharges are occurring?

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Table. Reviewed Studies
References	Purpose/Aim	Study Design	Sample/Setting	Findings
Ankuda et al⁵ (2018)	To examine relationships between the characteristics of hospice patients who elect full code status and LD rates	Retrospective review of electronic medical record data	25 636 decedents who were enrolled in 2 Michigan hospices between 2009 and 2014	12.9% had a full-code status. Of those, the likelihood of an LD were male, African American patients with CA, and living at home. Full code status was associated with a higher LD rate and a shorter LOS prior to LD
Campbell⁶ (2015)	To understand the lived experience of adult patients and their families who experienced an LD due to decertification	A transcendental phenomenological design using open-ended interviews and journals	12 patients or family members aged 35–92 y	Findings included 2 primary themes: suffering " ASI…" and the paradox of hospice discharge
Campbell⁶ (2015)				These themes were supported by subthemes: abandonment, unanswered questions, loss of security, loneliness, uncertainty, anger and frustration, physical decline, bearing exhaustive witness, having and needing support, mixed feelings, not dying fast enough, and hospice equals life
Dolin et al⁷ (2017)	To explore hospice providers' perspectives on factors that influence LD from the Medicare hospice program	Qualitative, using semistructured telephone interviews	18 individuals representing 14 hospice providers across the country	Themes: difficulty with prognostication, fear of regulatory audits, rising market competition and hospice business practices, and challenges with inpatient contracting
Dolin et al³ (2017)	To examine the relationship between hospice profit margin and LD rates in freestanding hospices	Retrospective study	Medicare claims data (2012–2013) and cost reports (2011–2013) for 1439 freestanding hospices	The overall LD rate ranged from 1.8% to 82.7% (M = 13.4%). As operating and total margins increased, the rate of LDs increased. Hospices in the highest tertile (eg, with the highest live discharge rates) tended to have the largest proportion of black patients and longer lengths of stay in hospice and were newer. They also were more likely to be operating in Southern rural areas, and chain-owned for-profit entities
Dolin et al⁸ (2018)	To explore the relationship between aggregate reimbursement caps and LD rates of Medicare hospices	Retrospective, using hospice monthly average lengths of stay	2 026 456 discharged Medicare hospice patients in 2012–2013	LD rate was 13.5%. Those more likely to be LDs were nonwhite and female, live in a rural area, and have a non-CA diagnosis; they were also more likely to be enrolled in a for-profit, newer, chain-owned, and small- to medium-sized hospice. As a hospice grew closer to exceeding its aggregate cap on reimbursement, the probability that a patient would be discharged alive increased
Kaufman et al⁹ (2017)	To understand factors associated with prehospice hospitalization and the effect on hospice LOS and LDs	Retrospective cohort study	1248 Medicare recipients from 4 geographically diverse communities	23% of hospice episodes resulted in an LD. CVD was the most prevalent diagnosis associated with an LD. The odds of an LD were less likely for patients with CA or age >85 y. Increasing hospital use in the year prior to hospice admission was associated with reduced odds of an LD
LeSage et al¹⁰ (2015)	To describe the outcomes of patients who were discharged alive from hospice	Retrospective review of medical records of adults discharged alive from hospice from 2006–2011	80 patients who were discharged from hospice care from 1 hospice in Wisconsin	LD rate was 5%, with CVD as the most common diagnosis. Reasons for LD included no longer met criteria (57.5%), patient/family choice (30%), patient deemed unsafe (3%), and transfer to another hospice (10%). Average survival after discharge was 199.9 d
Prsic et al¹¹ (2016)	To study trends in live Medicare hospice discharges, including rates of burdensome transitions^a	Retrospective cohort study	All live Medicare hospice discharges that occurred within the first 6 mo of 2000, 2006, 2008, 2010, and 2012	The adjusted rate of LDs ranged from 16.4%, peaking at 19.1% in 2008, and decreasing to 18.8% in 2012. For-profit hospices had an adjusted LD rate ranging from 17.7% in 2000 to 22.7% in 2012; nonprofit was less, growing from 15.8% (2000) to 16.3% (2012). Burdensome transitions increased at an overall rate of 2.9% (2000) to 5.3% (2012). The frequency of for-profit hospice burdensome transitions outpaced that of nonprofits
Russell et al¹² (2017)	To describe the characteristics of patients who were discharged alive from hospice	Retrospective cohort study using an electronic database of hospice patient records	9190 hospice patients covered by a nonprofit hospice organization in New York City between 2013 and 2015	LD rate was 21%. Reasons and risk factors included (1) acute hospitalization (42%): more likely in patients who were younger, of a racial/ethnic minority, and without an advance directive; (2) transfer or service move (25%): more likely among Hispanics and those with no primary caregiver or advance directive; (3) elective revocation for disease-related treatment (18%): more likely in patients of a younger age, nonwhite, and without a primary care provider or advance directive; (4) not eligible for hospice services (14%): more likely among women, with no advance directive, a non-CA diagnosis, and healthier with fewer comorbidities
Taylor et al¹³ (2008)	To describe hospice discharge patterns in a nationally representative sample of age-eligible Medicare recipients	Retrospective	1218 age-eligible Medicare recipients who used hospice services between 1991 and 2000	LD rate was 15.5%. LD was associated with a significantly longer survival time than those continuously enrolled in hospice. The likelihood of an LD was not significantly associated with a non-CA diagnosis, differences in demographics, comorbidity, or use of Medicare-financed health care services
Teno et al¹⁴ (2015)	To describe characteristics of hospices with problematic patterns of LDs	Retrospective	996 208 Medicare hospice discharges in 2010	18% were LDs. ''Problematic patterns'' of LDs included LDs followed by a hospital admission to the hospital and discharge, followed by hospice readmission within 2 d, hospice lengths of stay of ≥180 d, and discharges after an LOS of ≥7 d. For-profit hospices without a chain affiliation were most likely to have patterns of problematic discharges 18.2%; nonprofits had the lowest rate (1.4%)
Teno et al¹⁵ (2014)	To describe patient and organizational characteristics associated with LDs	Retrospective cohort study	182 172 Medicare patients discharged alive from hospice in 2010	18.2% were LDs. Individual state rates varied widely, from 12.8% (Connecticut) to 40.5% (Mississippi). Blacks and Hispanics were more likely than whites to be discharged alive, and patients with dementia, failure to thrive, cerebral vascular accident, congestive heart failure, and pneumonia were more likely to be LDs. Not-for-profit hospices had lower LD than profit; older hospices had lower LD rates than those open for ≤5y
Wladkowski⁴ (2017)	To understand the overall experience of an LD for caregivers of persons with dementia	Qualitative, using semistructured interviews	24 caregivers: 15 daughters, 4 sons, 3 significant others, and 2 nonfamily health care agents	Three themes emerged: (1) loss of support from the hospice team (loss of specialized support for the caregiver, loss of a direct caregiver, loss of the extra layer of care within skilled nursing facilities), (2) loss of the comprehensive service benefit and model of care (loss of equipment, supplies, and the flexibility of health care decision making), (3) caregivers' experience with the LD process (abrupt end, suggestions to improve LD process)

Abbreviations: CA, cancer; CVD, cardiovascular disease; LD, live discharge; LOS, length of stay.
^aDefined as a hospice live discharge followed by a hospital admission, with a subsequent hospice readmission within 2 days of leaving the hospital.

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Live Discharge From Hospice: A Systematic Review

Abstract and Introduction

Abstract

Introduction

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References

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