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Utahns at the end of their lives are less likely to die in hospitals than other Americans, spend fewer days in the hospital in their last six months and receive more days of hospice care than elders in all but one other state.
That's according to a new review by the Dartmouth Institute for Health Policy & Clinical Practice Atlas Project, which updates a similar study released in 2008. The earlier study also showed elders in Utah are less likely to undergo invasive tests and treatments, to spend time or die in intensive care units hooked up to beeping machines when there is no chance of recovery.
The study of chronically ill Medicare patients who died between 2003 and 2007 focused on people who were hospitalized during their last two years of life. It showed that:
• Utah residents at the end of their lives spent the fewest number of days in hospitals in the nation — 6.4 days, compared to a national average of 11.2 days.
• Only 12 percent of those who died spent time in an ICU, the nation's lowest rate.
• Utahns who died received more days of hospital-related hospice services than any other state except Oklahoma, and close to twice the national average.
• From 2003 to 2007, the University of Utah Hospital, the only one in the state affiliated with a medical school, saw a significant decrease in hospital deaths of elder, chronically ill patients — down to 21.3 percent from 31.5 percent.
"End-of-life care in the United States is changing, and changing rapidly," Dartmouth report co-author and physician David Goodman said Monday. "Patients are spending less time in hospitals ... and are more likely to receive hospice care."
At the same time, hospitals for a variety of reasons were shown to be giving more aggressive care to patients, the authors said, raising questions about whether institutions are paying enough attention to what dying people actually want.
Goodman said there has been a tremendous investment in new ICU beds. The increase in capacity can provide great benefits, he said, but can also lead to too many end-of-life patients receiving curative treatment with little hope of success.
Study co-author Elliott Fisher, also a physician, said patients have been more willing to receive hospice care, which focuses on keeping dying people comfortable and with their families, when they are told they don't have to forgo all curative care.
But the statistics indicate that doctors and hospitals at times still fail to inform patients of all their options, and fail to make sure treatment lines up with patients' wishes, the authors said.
When patients are being treated by 10 or more doctors — as some in the study were — the complexities of communication get in the way of listening to patients and families. Even patients willing to do without curative treatments may not be well-served by their providers. "Hospice care by itself doesn't mean ... that the care is aligned with patient preferences," Goodman said.
Dan Hull, executive director of the Utah Hospice & Palliative Care Organization, said that because the Dartmouth study focuses only on hospitals, it misses Utah's larger successes with end-of-life care, such as all the patients who go into hospice without first going to the hospital.
"This study's only part of what's happening," Hull said. "We have increased the length of stay and probably doubled the numbers you're reading."
When the Medicare Payment Advisory Commission, an independent congressional agency, did a kind of market study that measured how many patients who wanted hospice actually got it, he said, the Beehive State came out on top.
"Utah was at 70 percent," Hull said. "Other states were down in the 30 percents. The closest was 60 percent. Utah really does have a higher penetration of hospice."
Hull credits a concerted education effort about a decade ago that included getting doctors to come around to the idea of comfort care. Ten years ago, he said, only about 30 percent of dying people used hospice services.
The Terri Schiavo case that lasted from 1998 to 2005, as Schiavo's husband fought her parents to allow her to die rather than exist in a persistent vegetative state, helped make the public more aware of hospice, Hull said. So did the debates over assisted suicide.
Now, he said, federal budget writers are thinking about cutting hospice service. "You know you've arrived," Hull said, "when they talk about cutting you."
While the new study didn't focus on the costs of Medicare or other health care, the 2008 Dartmouth study showed that Utah's focus on getting people hospice services so they can die at home translated to the second-lowest Medicare spending on inpatient care in the country.
So, said Fisher, palliative care not only costs less and prevents excessive suffering, it actually helps elders live longer. On average, patients with limited prospects of survival for a year prefer to spend as much time as possible with their families.
Yet there is evidence those cries aren't being heard. "We still have serious barriers," Fisher said, "with implementation of palliative care."
Tribune reporter Tony Semerad contributed to this report. —
The study Dartmouth Atlas
A national statistical study shows chronically ill elders spent fewer days in the hospital and received more hospice care in 2007 than in 2003. At the same time, hospitals have intensified care, leading to questions about whether doctors are heeding patients' end-of-life wishes.