Study Casts Doubt on Hospice Admission Criteria for
Patients With Dementia11/02/10
TUESDAY, Nov. 2 (HealthDay News) -- Many people with advanced
dementia aren't getting much-needed hospice care because the
admission criteria is flawed, researchers say.
"Dementia is a leading cause of death in the U.S., and hospice care can benefit patients with dementia. The main hindrance to getting palliative [comfort] care is guidelines that try to guide practitioners to wait until an estimated life expectancy of six months," said Dr. Susan L. Mitchell, a senior scientist at the Institute for Aging Research at Hebrew SeniorLife in Boston, and lead author of a new study.
Such end-of-life predictions are difficult to make with
certainty in dementia cases. Instead of using life expectancy as
the requirement for admission, hospice care for dementia patients
should be offered based on the patient's and family's desire for
comfort care, suggest Mitchell and colleagues in the study
published in the Nov. 3 issue of the
Journal of the American Medical Association.
Hospice, or palliative, care is most often associated with
cancer patients. The goal is to provide comfort and support to
patients and their families, instead of life-prolonging
For people with cancer, the decision to switch to palliative
care is more clear-cut. It generally occurs when someone decides to
forgo traditional cancer treatments, such as chemotherapy or
radiation, that don't seem to be working anymore, and instead
receive comfort care, which includes better pain management and
discussions about important end-of-life care decisions.
For people with dementia, the decision process is murkier. Most
people with advanced dementia are already in nursing homes,
receiving around-the-clock care, but palliative care can provide
families with additional support and help families make difficult
decisions, such as whether or not to treat infections with
antibiotics or to use a feeding tube to deliver nutrition.
Palliative care may also provide better pain management and symptom
relief, said Mitchell.
To improve the likelihood of dementia patients getting
palliative care, Mitchell and her co-authors tried to come up with
a better tool to assess their potential life expectancy.
This new method, dubbed the Advanced Dementia Prognostic Tool
(ADEPT), includes 12 items, such as body mass index, ability to
perform tasks of daily living like self-feeding, bowel
incontinence, shortness of breath and oral food intake.
The researchers compared their assessment tool with the standard
Medicare hospice eligibility guidelines on 606 residents in 21
Their tool accurately predicted a life expectancy of fewer than
six months 67 percent of the time, versus 55 percent for the
Medicare guidelines, said Mitchell.
"While ADEPT was better than the Medicare criteria, its predictive ability isn't perfect," said Mitchell. "The delivery of palliative care should be guided by a preference of comfort care rather than by life expectancy," she added.
A 2009 study by Mitchell and her colleagues was the first to
label dementia a terminal illness like cancer and other incurable
Dr. Joseph Shega, an associate professor in the section of
geriatrics and palliative medicine at the University of Chicago
Medical Center, said he agrees that the issue of comfort care for
dementia patients deserves attention.
"It's important to recognize that we're not really good at figuring out how long someone with dementia might live, and I agree with these authors that we should focus more on the goals of care and stop spending resources on trying to figure out how long someone might live," said Shega.
"Hospice provides more support for nursing home staff, better support for the family, and can help better educate the family on the natural process of dementia so they know what's going on," he explained.
Hospice also helps manage symptoms, like discomfort or
agitation, Shega added, while making sure that care plans and
treatment goals agree with the values and wishes of the patients
and their families.
Read more about dementia and end-of-life care from the
U.S. National Institute on Aging.
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