Barbara Bush died yesterday after a very short period of comfort care after she elected to stop any further attempts at curative care. She may or may not have received formal hospice care.
A source close to the Bush family tells CBS News’ Jenna Gibson that, while Mrs. Bush’s COPD makes it difficult for her to breathe, she is alert and was having conversations last night. She was also having a bourbon.
— Katie Watson (@kathrynw5) April 17, 2018
If I was 92 and knew that I was going downhill, I think I would elect Scotch over bourbon. I would also elect to spend what uncertain time I had left at home with family and friends instead of in the hospital where the quantity of remaining life may be greater at no better and probabilistic lower quality of life.
If she had elected hospice care, she would have had a very short span of hospice utilization. Hospice qualification for someone covered by Medicare has a fairly strong normative pathway. An individual will be identified as having a high probability of death within the next 180 days in the opinion of the treating physician and the medical director of the admitting hospice. Once an individual elects hospice, they give up curative care for the primary diagnosis that led to hospice. Ideally, then the individual uses hospice for several weeks to a few months. Short spans of less than a week and long spans of more than six months are seen as meaningfully problems.
MedPac’s 2018 report on hospice utilization repeats a common sentiment that echoes years of previous statements:
The Commission has previously expressed concern about very short hospice stays. More than one-quarter of hospice decedents enroll in hospice only in the last week of life, a length of stay that is commonly thought to be of less benefit to patients and their families than enrolling somewhat earlier. Very short hospice stays (e.g., 25th percentile) occur across a wide range of diagnoses
We are also moving towards a medical system that is supposed to be “patient-centric” with a dozen distinctive definitions of what that actually means. The patient and their family are the drivers of decisions while the clinicians facilitate and illuminate pathways that can be chosen. So if a patient chooses to try one last round of treatment and then chooses to forego further curative care at the very end of life, how do we reconcile a strong normative belief on “proper” hospice utilization with patient centeredness?
Bourbon is recommended.