This article is a continuation of our series on heart failure and hospice care. In the previous article, we provided an overview of benefits and barriers for patients with life-limiting heart disease and hospice/palliative care providers. See the previous article Life-Limiting Heart Disease and Hospice Care – Part 1.
Previously, we covered the disease factors that introduce barriers to receiving hospice and palliative care for patients with heart disease. The progression and prognosis of heart disease provides several barriers to providing a referral to hospice and palliative care. In addition to disease factors, policy factors exist which are impediments to referrals.
There are three major policy factors which provide impediments to hospice referrals for patients with heart failure.
- 6-month survival rate
- Low fixed daily payment rate
- No concurrent care options
Most insurers require a 6-month survival rate prognosis for hospice or palliative care referrals. The disease trajectory of heart failure makes an accurate prognosis difficult. As covered in the previous article, patients can experience a gradual decline with intermittent exacerbations, that upon a treatment may return the patient to a near-normal pre-incident state. It is difficult to predict which incident will result in a life-limiting prognosis. Lastly, a single incident may trigger a need for an immediate hospice referral. Thus, it is difficult for a medical provider to provide a hospice referral when a 6-month prognosis may be in doubt.
Heart failure is a care-intensive disease. Patients who lack family to provide care or pay for care may be unable to remain at home with hospice care. Lower median incomes have forced many patients with heart failure to rely on hospital admissions for care. Many studies have shown a link between low socioeconomic status and more aggressive care at the end-of-life, increase chance of dying in a hospital, and lower likelihood of receiving hospice care.
Lastly, it would benefit patients and provide better outcomes to provide a concurrent care option. As stated above, a 6-month end-of-life projection is difficult where there is a chance a curative procedure might restore the patient to near-normal health. However, advocates are pushing for a concurrent care option where patients can receive supportive care while also pursuing curative treatment. Hospice can provide needed relief to patients who may, or may not, respond to curative treatments.
Underuse of hospice care for people with heart failure is a significant public health problem. The need for hospice care exists but the policy barriers to referrals need to be removed. Removing the 6-month survival rate, increasing daily payments, and allowing for concurrent treatment plans should be considered to provide better outcomes for patients with heart failure.