Live Discharge From Hospice: A Systematic Review

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

Disclosures

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

In This Article

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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