America has built a culture and quality metrics that push families and physicians to send patients home to die, but dying in the hospital can be a peaceful and dignified option for patients with complex conditions, Daniela Lamas, MD, a pulmonary and critical care physician at Boston-based Brigham and Women’s Hospital, wrote in an opinion piece published Sept. 28 in The New York Times.
“An ICU death can be peaceful and dignified,” Dr. Lamas wrote. “A death at home can be panicked and painful. Yet we have built a culture, and quality metrics, that treat ICU care at the end of life as a failure.”
This preference for death at home came from practices about 50 years ago, when most Americans died in hospitals and often received painful, aggressive interventions that they may not have wanted had they understood their prognosis. Today, about a third of Americans die in hospitals, largely due to the rise of hospice and palliative care. As part of this change, Medicare tracks the percentage of patients admitted to the ICU in their final 30 days of life, which Dr. Lamas said made intensive care become “something to be measured and minimized.”
“Home hospice can be deeply meaningful,” Dr. Lamas wrote. “But home is not always the easiest place to manage the complexities of dying. For patients with severe or rapidly changing symptoms, a nurse is not down the hall at 2 a.m. When pain or breathlessness becomes difficult to control, families can panic and call 911.”
Dr. Lamas said she has become more hesitant to recommend home hospice, but “the cultural script that tells us that love looks like dying at home is powerful, and it leaves people who couldn’t make that happen — for reasons of symptoms, of resources, of fear — certain that they let someone down.”
For example, Dr. Lamas shares that she recently cared for a dying patient in his 50s with esophageal cancer. The family thought taking him home was the right thing to do, but the day before he was to go home to hospice, his symptoms worsened. Because he was in the hospital, his care team was able to provide more medication that would have been impossible to give at home.
“We decided that he would stay in the ICU,” she said. “His family members were not upset; if anything, they were relieved. They had thought going home was something they should do for him, but they weren’t sure they were equipped to do it. He died in our hospital, with family at his bedside. Those family members were free simply to be his family — holding his hand, not try to manage his medications. I don’t think that can be called a failure.”
