Health Spotlight

End-of-Life Care in VA

June 2006

End-of-life care deals with the physical, psychological, social, spiritual, and practical needs of people who are nearing the end of their lives. For the chronically ill, elderly, and/or frail, end-of-life care may require a team of medical professionals, including a treating doctor, the patient's family, and social services representatives.¹ This group helps manage the following aspects of the patient's care:

• Pain management-by working together, they can identify pain sources and alleviate the pain with medication or other means.
• Symptom management-focuses on treating symptoms other than pain, such as nausea, bowel and bladder problems, mental confusion, fatigue, and breathing difficulties.
• Emotional and spiritual support-important for both the patient and the family dealing with the stress and anxieties associated with nearing death.¹

Hospice Care

Hospice care can be part of end-of-life care and is used to assist individuals with terminal illnesses. Hospice care may be used in the last months or weeks of life to make the dying process more comfortable.

Hospice care can be provided in the patient's home or in a facility designed to provide end-of-life care. Goals of this type of service include:

• Pain management,
• Counseling for the patient and those close to him/her,
• Relief for the patient's caregivers, and
• Creation of a comfortable environment for the patient.²

End-of-Life Care for Veterans

There are some important factors health care providers need to consider when providing end-of-life care to veterans. For example, the effect of combat experience may remain in some veterans' subconscious for years, only to emerge when they are close to death. Caregivers need to acknowledge the possibility of additional anxiety and agitation related to these experiences that could occur, and may also want to keep the following factors in mind:

• Veterans dying in the VA system often have a higher degree of social isolation, lack of family support, and/or low income;
• Cultural differences of some individuals at end of life could prevent them from admitting to pain or asking for pain medication; and
• Most dying individuals resist physical and chemical restraints, but the resistance from veterans may be even more overwhelming.³

Current Efforts in VA

The VA health system recently made advances in refining and expanding palliative and hospice care, in part, because the number of veterans who require these services has greatly increased due to our aging veteran population. Hospice and palliative care are now covered services for all veterans, and this type of care is available through every VA facility. Additionally, VA has continued to work toward more comprehensive and coordinated end-of-life care. ³

For example, the Training and Program Assessment for Palliative Care (TAPC) includes a national survey to identify and describe actual end-of-life care practices in VA medical centers, and the National Hospice-Veteran Partnership Program is actively promoting collaborations between VAMCs, community hospices, and other groups to improve access to hospice and palliative care programs for veterans.³ Visit www.hospice.med.va.gov for additional information on the Nationwide Palliative Care Network.

HSR&D Research

HSR&D has posted an online advance directive workbook to assist patients and family members. Your Life, Your Choices is the product of an HSR&D-funded research project that evaluated the effectiveness of a comprehensive advance care planning intervention. It provides guidance regarding a Living Will, how to create an advance directive, and how to discuss related issues with family and health care providers. Visit www.hsrd.research.va.gov/publications/your_life/ to view the workbook.

Below are examples of additional HSR&D research aimed at improving end-of-life care for veterans.

Improving the Quality of End-Of-Life Care in Nursing Homes

Despite that hospice care in nursing homes and other settings is associated with improved outcomes, only one in four nursing home residents enrolls in hospice before death. This study sought to determine whether an intervention that promotes communication about hospice care would increase enrollment and improve the quality of end-of-life care for nursing home residents. The intervention consisted of an informational visit about hospice care. Investigators conducted a study of 205 residents in three different types of nursing homes (urban facility, suburban facility, and VA nursing home with diverse population) and monitored hospice enrollment over 30 days, as well as families' ratings of the quality of care for residents who died during the six month follow-up period. Researchers found that hospice enrollment rates were significantly higher in the intervention group (20%) compared to the control group (1%), and that surrogates' ratings of the care residents received in the last week of life were significantly higher in the intervention group.⁴

Differences in Health Care at the End-of-Life for COPD vs. Lung Cancer

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the U.S. Two previous studies compared patients with severe COPD and non-operable lung cancer and found that despite the fact that patients with COPD had worse health-related quality of life, depression and anxiety, they received fewer palliative care services. This retrospective cohort study examined health care use in the last six months of life between veterans who died with COPD, compared to those who died with lung cancer. Researchers found that during the last six months of life, veterans with COPD were twice as likely to be admitted to an intensive care unit and had five times the odds of remaining there two weeks or longer than those with lung cancer. Veterans with COPD also received care that was more consistent with prolonging life than palliation of symptoms, and costs for treating veterans with COPD were greater.⁵

End of Life Care: Medical Treatments and Costs by Age, Race, and Region

The number of veterans aged 85 and older grew from 223,000 in 1995 to 980,000 in 2005, but little is known about the overall level of healthcare utilization near the end of life at VA. In this study, researchers analyzed medical care costs and utilization patterns for five selected medical services (intensive care stays, mechanical ventilator use, pulmonary artery monitor use, dialysis, and cardiac catheterization) in both VA and Medicare facilities during the final two years of life for elderly VA patients. They also examined the aggressiveness of care, and variations due to cause of death, age, race, and geographic region. Assessing both VA and Medicare benefits, findings show that elderly veterans incurred an average of $43,795 in the final year of life, 40% more than an average Medicare beneficiary accrued during the final year of life. Investigators also found that selected aggressive medical treatments among veterans with acute hospital stays declined with increasing age, and that there was an increased use of other (non-acute) inpatient care as well as a decreased use of acute hospital care at the end of life.⁶

Other Ongoing Studies

VA researchers are conducting a variety of studies on end-of-life care, including A Randomized Trial of Care Management to Improve End of Life Care; Evaluation of a Cardiac Nurse Practitioner Palliative Care Program ; and Measuring Quality of Family Experience of Patients with Serious Illness.

References

1. Palliative Care. The Journal of the American Medical Association March 16, 2005; 293(11).

2. Hospice Care. The Journal of the American Medical Association February 8, 2006; 295(6).

3. Department of Veterans Affairs. VA Transforms End-of-Life Care for Veterans.

4. Casarett D, Karlawish J, Morales K, et al. Improving the Quality of End-of-Life Care in Nursing Homes: Results of a Randomized Controlled Trial. The Journal of the American Medical Association July 2005; 294:202-210.

5. Au D, Udris E, Fihn S, et al. Differences in Health Care Utilization at the End-of-Life Among Patients with COPD and Patients with Lung Cancer. Archives of Internal Medicine February 2006; 166:326-331.

6. Richardson SS, Yu W. Controlling for Patient Case Mix at the End of Life: Issues in Identifying Cause of Death. The Journal of the American Medical Association 2005; 294:793-794.