Quality of End-of-Life Care: Does Place of Residence Really Matter?

Background/Purpose: End-of-life (EOL) care is structured support delivered to people with terminal conditions and it is provided across various settings. A hospital setting is the least favored place to receive EOL care, while home and residential care facilities are identified as preferred by dying patients. Even though most individuals prefer to die at home, 50% eventually die in a hospital setting. The quality of EOL care in a specific setting is one of the biggest concerns for dying patients and their families to decide where to receive care in the last stage of life. However, few studies have examined and compared the quality of EOL care across various settings. Therefore our study aims to compare ten domains of EOL care among older adults in at-home settings versus residential care settings, and investigate whether disparities in quality of EOL care are evident.

Methods: This study used survey data from the National Health and Aging Trends Study, which collects information from a nationally representative sample of Medicare beneficiaries aged 65 years or older. A total of 1,176 participants who died between 2013 and 2016 were included. Information on EOL care experience during the last-month of life was obtained from proxies.  Depending on the place of residence and the involvement of hospice, participants were categorized into four groups: home-based care without hospice (n=417), home-based care with hospice (n=281), residential care without hospice (n=259), and residential care with hospice (n=219).

Quality of EOL care was evaluated using measures validated by a National Quality Forum. They examine ten domains of EOL care: the overall rating of care, doctors’ involvement, whether the decedent experienced pain, breathing troubles, and anxiety/sadness, whether the needs for personal care and religiosity were met, whether the decedent was treated with respect, the families were kept informed, and whether decisions about treatment were made appropriately.

Bivariate comparisons of four groups were conducted using Pearson’s χ² or ANOVA. Differences across quality of care domains were tested using multivariate logistic regression models adjusted for decedent’s race, sex, age at death, and the proxy’s age, sex, and relationship to the decedent. 

Results: Adjusted models indicated that older adults that resided in home-based settings with hospice reported the highest overall satisfaction with EOL care. Compared to those that resided in home-based settings without hospice, older adults who lived in settings with hospice were 80% less likely to have unmet needs for anxiety/sadness and 70% more likely to talk about religion; families of older adults that lived in residential care without hospice were two times less likely to be kept informed on patient status. Compared to those that received hospice at home, older adults who received hospice in residential settings were more likely to be treated with respect.

Conclusions and implications: Our findings indicate that involvement of hospice is associated with better quality of EOL. Specifically, regardless of care settings in the last month (home vs. residential care), hospice recipients tend to have better support across domains of spirituality and psychological well-being, e.g., anxiety and sadness.