Why do people who are enrolled in home hospice go to the Emergency Room or hospital? This is a question that I have thought about for a long time. Home hospice is a great service that can help most people at EOL stay at home if that is their preference. But…
“I know Daddy has bad dementia, but I think he has pneumonia! Couldn’t an antibiotic help?”
In a prospective cohort study conducted by our Birmingham VA palliative care research team, we found that often there was a flare of symptoms that would be the prompt to leave the home.
While many home hospices provide a hospice emergency kit filled with essential medications that can be stationed in the home, some do not. These kits are not required by CMS hospice regulations and, although modest in cost, they are an expense. At the VA, we developed our own standardized kit so that all Veterans got the same medications. We put in a couple of antibiotic doses like levofloxacin for lung, bladder or even skin infection.
We followed a group of 43 consecutive patient/family dyads who were discharged with a kit. Weekly, our team called them to see what was happening. Two out of three patients used something from the kit at least one time and one out of four had used the kit two or more times. As expected, the morphine concentrate was the most commonly used medication. However, 15% of the time the antibiotic was used. Half of the time when a medication in the kit was used, the family thought it had prevented a trip to the hospital/emergency room. The other half still made at least one trip back to the hospital for poorly controlled symptoms.
Home deaths, usually with home hospice, are highest in the zip codes with the highest average income and lowest in the low-income zip codes. This is probably something even a super-duper kit will not overcome. When a hospice patient comes back to the hospital when that is not their preference, we should think of it as a sentinel event and ask “Why?” and “What might have helped?”
Read the full VA study at:
Bailey FA, Williams BR, Goode PS, Woodby LL, Granstaff US, Echt KV, Redden DT, Kvale E, Burgio KL.Impact of a hospice emergency kit for veterans and their caregivers: a prospective cohort study.J Palliat Med. 2014 Aug;17(8):931-8. doi: 10.1089/jpm.2013.0395. Epub 2014 Jun 13.