The United Health Foundation recently ranked Texas No. 31 in health. The foundation also ranked the states on senior health, where Texas ranked 41st among the states.
The state’s challenges include more than 11 percent of seniors living in poverty and the prevalence of households with food insecurity, meaning inconsistent access to adequate food. Texas is among the top dozen U.S. states in terms of food insecurity for all ages, and has the second-highest number of food insecure households.
The state also has a low percentage of quality nursing home beds and the smoking rate among Texas seniors inexplicably rose by 10 percent.
But it wasn’t all bad news for Texas.
The state was lauded for its ample supply of home health care workers, low prevalence of teeth extractions and decrease in chronic drinking.
Two other notable accomplishments: the use of hospice care in Texas rose by 24 percent and the percentage of seniors dying in hospitals decreased by 21 percent in one year. About 80 percent of patients say they do not want to die in the hospital and a similar percentage do not want aggressive end-of-life treatment. Hospice and palliative care are the opposite of that aggressive care, and Baylor Scott & White Health excels at both.
Many people –- including some physicians –- confuse palliative and hospice care. Non-hospice palliative care addresses symptoms regardless of prognosis. Hospice is a subset of palliative care for those who are believed to be in their last six months of life. Some fear health care providers will not try as hard to cure them if they ask for palliative care. Others believe hospice is a “place” rather than a form of care that can be delivered in various locations.
Hospice care depends on a physician’s estimate that a patient will live no longer than six more months. However, hospice care will continue after that time as long as the physician and caregivers certify that the patient’s condition is terminal.
Hospice and palliative care typically are underused. Many experts say their use depends on what they call medical culture, which can vary regionally. In some areas, physicians put a higher premium on treatments and tests for end-of-life care.
Some physicians also equate suggesting hospice with “giving up.” The American Society of Clinical Oncology issued a policy statement in February 2011 to urge oncologists to speak candidly with incurable patients about end-of-life treatment options. At the time, fewer than 40 percent did so.
Baylor Health Care System’s Supportive and Palliative Care program is one of three U.S. programs to be honored this year by the American Hospital Association (AHA). The award’s judges cited the success of the program’s ability to foster a culture that supports palliative care. However, the same efforts also can promote the use of hospice in health systems.
Robert L. Fine, MD, the program’s director, credits the Texas Advance Directives Act (TADA) that helped change the medical culture statewide, leading to high hospice utilization. He was the lead physician author for TADA in 1999 and wrote the state’s official living will based on pioneering efforts by Baylor’s clinical ethics committee.
Dr. Fine said the Texas definition of terminal illness matches the one used by the Medicare hospice benefit.
“In many states, terminal illness, the point at which one’s living will comes into play is defined as ‘death is imminent,'” Dr. Fine said. “The Texas living will was the same way.”
“I pointed out (in drafting new legislation in 1998-99) that the imminent death standard for honoring a living will kept patients in the hospital to die because too many physicians were unwilling to say death was imminent until hours or at most a few days before death. Not only were we able to expand the definition of terminal illness to match the Medicare hospice criteria, we created within the law the concept of irreversible illness and wrote that specifically with geriatric patients in mind,” he said. “Many elders would ask to be allowed to die in the setting of advanced dementia or an incapacitating stroke, but prior to changing the law in 1999, these patients were often forced to endure a long slow decline, again because their death was not imminent and therefore their living will did not come into effect.”
Dr. Fine said higher hospice utilization is advantageous for patients because it is more likely to deliver higher-quality end-of-life care, is associated with lower health care costs, and has been associated with longer survival at a certain point in the progression of heart failure and many cancers.